CARCINOMA

TONGUE
MEGHA S KABEER
S4
114
CARCINOMA
TONGUE
 CASE
65 year old male, addicted to smoking and pan
chewing , presented with non healing ulcer in
the right lateral aspect of the tongue . The
ulcer is 3*2cm in size. He has profuse
salivation and carries a handkerchief for
wiping the saliva.
He also complains of earache in the right ear
He has difficulty in tongue protrusion. There is a
slight slurring of speech.
There is an offensive smell when he speaks .
The submandibular lymph node on the right side
is enlarged firm and mobile of about 2*1 cm.
Jugulodigastric lymph nodes on oth sides are
firm enlarged and mobile
 CARCINOMA TONGUE
• Carcinoma tongue is the second common oral
malignancy after carcinoma lip
• Used to be more common in men than
women. Now it is almost equal due to an
increase in number of female smokers
• Commonly affects people over the age of 65
LYMPHATIC DRAINAGE
 RISK FACTORS
1. Tobacco
2. Alcohol
3. Areca nut / Pan masala
4. Poor nutrition
5. Inherited conditions – Fanconi anaemia , Li
Fraumeni syndrome
6. Human papilloma virus (HPV), EBV
7. Premalignant lesions of oral cavity
 6S
1. Spices
2. Spirit
3. Sepsis
4. Sharp tooth
5. Syphilis
6. Smoking
 CONDITIONS ASSOCIATED WITH
MALIGNANT TRANSFORMATION
HIGH RISK LESIONS:
1. Erythroplakia – homogenous or speckled
2. Proliferative verrucous leucoplakia
3. Chronic hyperplastic candidiasis
MEDIUM RISK LESIONS:
4. Oral submucosal fibrosis
5. Syphilitic glossitis
LOW RISK /EQUIVOCAL RISK LESIONS:
1. Oral lichen planus
2. Discoid lupus erythematosus
3. Discoid keratosis congenita
ERYTROPLAKIA:
LEUCOPLAKIA
 TYPES :
GROSS:
1. Papillary
2. Ulcerative or ulceroproiferative
3. Fissure with induration
4. Lobulated indurated mass – frozen tongue
HISTOLOGICALLY:
1. Squamous cell carcinoma (MC)
2. Adenocarcinoma
3. Melanoma
4. Transitional cell carcinoma
5. Lipoepitelioma
 SITES :
1. Lateral margin : 47-50%
2. Posterior third : 20%
3. Dorsum : 6.5%
4. Ventral surface : 9%
5. Tip : 10%
 CLINICAL FEATURES:
1. Painless ulcer/swelling in the tongue which
later may become painful.
I. infection
II. ulceration
III. due to the involvement of lingual nerve (pain is
referred to ear).
2. Pain on swallowing ( Ca posterior 1/3 of
tongue) 
3. Excessive salivation. Often blood stained.
4.Dysphagia
I. fixed tongue
II. due to the involvement of  genioglossus
III. growth in the posterior third of the tongue. 
5. Visible ulcer in anterior two-thirds of tongue
– Ulcer can bleed on touch
– edge, base and surrounding areas are indurated.
– indurated area is much more extensive than the
primary tumour
– Edge is everted  
– Ulcer may cross the midline; may extend into the
floor of the mouth/alveolus/mandible
Growth or ulcer in posterior third, is  usually not visible.
6. Ankyloglossia—involvement of muscles of
the tongue.
7. Movements of the tongue (especially
forward protrusion ) affected.
8. Inability to articulate.
9. Foetor (Halitosis)-
– infection and necrosis in the oral cavity. 
– release of ammonia, butyric acid and
mercaptan by tumour cells.
10. Change in voice (posterior third tumours). 
12. Palpable neck nodes - hard, nodular and
get fixed in advanced stages. 
13. Features of bronchopneumonia—due to
aspiration during lying down/sleeping mainly
to lower segment of lung.
 SPREAD OF CARCINOMA TONGUE 
LOCAL SPREAD:
A. Anterior two-thirds of tongue
  Genioglossus muscle
 Floor of the mouth and opposite side
 Mandible
B. Posterior third of tongue  
 Tonsil
 Side of pharynx
 Soft palate, epiglottis
 Larynx
 Cervical spine.
LYMPHATIC SPREAD: 
1. Tip of tongue - submental nodes
2. Lateral margin -submandibular lymph nodes ,later
to deep cervical lymph nodes
3. Posterior third –pharyngeal nodes and upper deep
cervical lymph nodes.

Lymphatics in the tongue are freely communicating, and

so involvement of bilateral neck lymph nodes is
common.
 Carcinoma tongue has got highest incidence of nodal
spread
LYMPHATIC DRAINAGE
 INVESTIGATIONS:
1. Wedge biopsy
2. FNAC of lymph nodes
3. Indirect and direct laryngoscopy to see posterior third 
growth. 
4. CT scan to see the extension of posterior third growth,
or to see the status of lymph node secondaries.
5. MRI is also very useful to assess the extent of primary
tumour.
6. Chest X-ray to see bronchopneumonia.
7. Orthopantomogram.
SURGERY
RADIOTHERAPY
CHEMOTHERAPY

TREATMENT
 SURGERY :
1. Tumor <1cm OR Carcinoma insitu :
– Wide excision with 1 cm clearance in margin and depth
– CO2 laser
– Brachytherapy by iridium wires
2. Tumor 1- 2cm : Partial glossectomy ( 2 cm clearance
from the margin + removal of 1/3rd of anterior two-
thirds of the tongue)
3. Tumour > 2 cm : Hemiglossectomy (with removal of
anterior 2/3rd of tongue on one side up to sulcus
terminalis)
4. Extensive lesion involving the floor of mouth
and alveolus
– Major 3 dimensional resection by lip split and
mandiulotomy
– Marginal mandibular resection
– Dissection of neck on same side
– Wide excision or hemiglossectomy+
hemimandibulectomy+radical neck =commando
operation
 RAW AREA
• WIDE:
– left alone to granulate and heal by epithelialisation
– quilted split-skin-graft
– Radial forearm flap with microvascular anastomosis
– AL thigh
– Rectus abdominis
– Medial sural artery perforator
– deltopectoral flap, forehead flap, pectoralis major muscle flap

• SMALL - primary suturing.
Larger primary tumour can be given pre-operative
radiotherapy, then later hemiglossectomy is done. 
Same side palpable, mobile lymph nodes are removed by
radical neck block dissection. 
Bilateral mobile lymph nodes are dealt with one side radical
block and other side modified radical block dissection
with essentially retaining internal jugular vein (on
opposite side) to maintain the cerebral venous blood flow.
Other option is doing same side radical neck dissection
and on opposite side supraomohyoid block dissection
 POSTOPERATIVE MANAGEMENT:

• Control of infection and oedema

• Regular mouth wash
• Maintaining the airway
• Prevention of aspiration
• Nutrition (through nasogastric tube
commonly/TPN often)
 2. RADIOTHERAPY:
1. Small primary tumour—curative radiotherapy
(Brachytherapy  using caesium or iridium192
needles).
2. Large primary tumour— preoperative tumor size
reduction
3. Advanced primary & secondaries - palliative
external radiotherapy. 
4. Post-operative radiotherapy - large tumours to
reduce the chances of relapse. 
5. Posterior third of tongue –curative and palliative
COMPLICATIONS OF RADIOTHERAPY
1. Loss of sensation like taste
2. Trismus and ankyloglossia
3. Infection
4. Pharyngeal and laryngeal oedema
5. Dermatitis and skin infection
 3. Chemotherapy:
•  Given in post-operative period and also for palliation.
• Price-Hill regimen is commonly used. Drugs are
methotrexate, vincristine, adriamycin, bleomycin and
mercaptopurine.
• It is either given intra-arterially, as regional
chemotherapy through external carotid artery using
arterial pump or through IV. It can also be given orally.
• For Melanoma, Melphalan and DTIC are used. 
• Anterior chemotherapy (pre-operative) is becoming
popular to downstage the tumour
COMPLICATIONS OF CHEMOTHERAPY
1. Megaloblastic anaemia
2. Bone marrow suppression
3. Alopecia
4. Sepsis
 TERMINAL EVENTS

1. Inhalational bronchopneumonia
2. Haemorrhage from erosion of lingual artery.
In posteriorthird of the tongue, erosion of
internal carotid artery can occur
3. Cancer cachexia and starvation
4. Asphyxia due to pressure on air passages or
due to oedema glottis
 PROGNOSIS :
Five-year survival for females is 50%, for males is 25%.

PROGNOSTIC FACTORS 
x Size of the tumour > 4 cm carries poor prognosis. 
x Site of tumour (posterior third has got poor prognosis).
x Tumour crossing the midline.
x Lymph nodes status.
x Differentiation.
x Bone involvement. 
NODAL PROGNOSTIC FACTORS
 Positive histology in node reduces the survival
 Level III and IV has poor prognosis
 Bilateral/contralateral nodes carry poor
prognosis
 Extracapsular spread/size > 3 cm carry poor
survival
 > 3 in number of nodes involved is poor sign
 CARCINOMA OF POSTERIOR ONE-
THIRD/BASE OF THE TONGUE :

Lesion may remain asymptomatic for long time.

Clinically may be missed easily. 
CLINICAL FEATURES
• Earlier symptoms are features mimicking sore-throat and
throat  discomfort.
• Dysphagia and change in voice (hot potato voice) occurs later. 
• Referred pain in the ear
• bleeding from mouth
• visible mass in posterior third
• Induration on palpation is diagnostic
• Abundant lymphatics which cross communicates on either
side-
– lymph node spread is common (70%)
– usually B/L 
– Massive nodes
– involvement of jugulodigastric node. 
• Infiltration into the tongue muscles like genioglossus,
epiglottis,  pre-epiglottic space, tonsillar pillars and
hypopharynx
• Often poorly differentiated and carries poor prognosis
• Blood spread can occur into bones, liver and lungs in
posterior third cancers. 
• Presentation as unknown/occult primary and often with
blood  spread can occur
 MANAGEMENT:
Palpation under anaesthesia gives better idea about the
tumour, its spread and also allows the biopsy. 
CT scan/MRI is always needed to plan the staging and therapy. 
1. T1, T2, N0 and N1 –
– wide excision or  total glossectomy using midline
mandibulotomy incision (mandible split)
– 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. 
2. Advanced lesions –
– palliative radiotherapy or chemotherapy. 
– T4 lesions are often treated by total glossectomy with
laryngectomy  and neck dissection
THANKYOU