1. Dr.P.Viswakumar, Assistant professor, Dept. of General surgery, PSGIMSR, Cbe-04 Carcinoma Tongue 2. Anatomy of Oral cavity Extends from skin- vermilion junction of lips to junction of hard and soft palate above Below it is limited to circumvallate papilla of tongue. 3. Structures included Lips, Buccal mucosa, Upper and lower alveolar ridges,the retromolar trigone,anterior two thirds of tongue,floor of mouth and the hard palate. Again it is divided into external compartment vestibule and inner oral cavity proper by alveolar ridges and teeth. 4. Buccal mucosa 5. Sensation : 2nd and 3rd branch of Trigeminal nerve. Motor : Facial nerve Lymphatics : Parotid and level 2 lymph nodes of neck 6. Hard Palate 7. Importance of hard palate : -Mucosa and periosteum are closely adherent. -These foraminas are potential route of spread of malignancies anteriorly to nasal cavity and posteriorly to skull base. -Lymphatic drainage through level II if in posterior hard palate and both primary hard palate drains into level I nodes. -Sensation is by V 2 8. Retromolar trigone 9. Importance of Retromolar trigone Mucosa is closely adherent to the ascending ramus of the mandible. Carcinoma in this region often invades mandible. Referred otalgia results from innervation by V3,lesser palatine nerve, and the glossopharyngeal nerve. Lymphatic into Level II nodes. 10. Floor of the Mouth 11. Tongue 12. Salient features Sulcus terminalis divides the tongue into anterior 2/3rd and posterior 1/3rd. Anterior 2/3rd is part of oral cavity and posterior 1/3rd part of oropharynx. Anterior part is derived from lateral lingual swellings of first branchial arch and got lingual nerve as sensory supply. 13. Muscles of Tongue Broadly divided into 1) Extrinsic and 2) Intrinsic group 14. Muscles of Tongue Extrinsic : 3 pairs 1) Styloglossus 2) Hyoglossus 3) Genioglossus Intrinsic : 3 groups 1) Vertical. 2) Longitudinal. 3) Transverse. 15. Innervation and Drainage Motor : Hypoglossal nerve Sensory : Lingual/Taste by Chorda tymphani via facial nerve. V3 also supplies EE,EAC,TM Tongue malignancy has referred pain over ear. Arterial : Lingual artery Lymphatic : Tip Level I A Lateral aspect @ Level II nodes Medial aspect into Level III nodes Lateral drains only in Ipsilateral nodes Medial can drain in both ways. 16. Incidence of Oral malignancy India continues to report the highest prevalence of oral cancers globally with 75,000 to 80,000 new cases of such cancers reported every year. 57.5 % of global head and neck cancer occurs in Asia esp in India. Head and neck cancer accounts 30% of all cancers in Male and 11-16% of females in India. Nearly 2/3rd of oral cancer in India occurs in Gingivo-buccal sulcus and hence it is popularly called Indian oral cancer. 17. Distribution of cancer in Oral cavity 18. Etiology 19. Etiology 20. Etiology 21. Tobacco use in dose dependent fashion. Alcohol has synergistic effect. It takes 20 years for a smoker or tobacco chewer who abstained from above to clear of their risk of developing tumor. In India tobacco along with betel nut chewing contributes 25 % of cancers in oral cavity. 75% of Squamous cell carcinoma occurs only in 10 % of mucosal areas. Those are Gingivobuccal sulcus,lateral border of tongue to retromolar trigone and the anterior tonsillar pillar. This is due to flow and pooling of carcinogen contaminated saliva in these regions. 22. Human papillomaviruses (HPVs) have been associated with a risk for oral cavity . These carcinomas may carry a better prognosis and may respond better to therapy such as radiotherapy. A nested case-control study suggested that the risk may be with the HPV-16 serotype, with 50% and 14% of oropharyngeal and oral tongue carcinomas, respectively, containing HPV-16 DNA. The EBV is a human herpesvirus that has been implicated in a number of human malignancies, including nasopharyngeal carcinoma (NPC). 23. Premalignant lesions 24. Pathology Squamous cell carcinoma accounts for 95% of all malignant tumors in the oral cavity. Other malignancies involving the oral cavity include malignant salivary gland lesions, mucosal melanoma, lymphoma, and sarcoma. In the earliest recognizable stage, squamous cell carcinoma appears as firm, pearly plaques or as irregular, roughened, or verrucous areas of mucosal thickening. 25. Clinical presentation Non healing ulcer Other tell-tale sign of head and neck malignancy 1) Otalgia 2) Odynophagia 3) Bleeding 4) Dysphagia Pertaining to tongue : Restriction of movement of tongue,difficulty in pronounciation. 26. Pretreatment evaluation Complete head and neck examination Examination under anaesthesia if necessary. Biopsy(Wedge biopsy) of primary lesion or suspicious ones. FNAC of suspicious/enlarged/palpable lymphnodes. CT/MRI of primary and neck. X-ray chest to rule out synchronous primary. 27. Other important things Dental evaluation Examination under anaesthesia 1) Direct laryngoscopy and pharyngoscopy 2) Esophagoscopy. 3) Bronchoscopy. 4) Palpation of tongue and oropharynx. Councelling about speech loss and therapy. 28. STAGING 29. Treatment Options Dr.Haris PS/ OMR36 T1N0, T2N0 Surgery RT RT -External Beam -Brachytherapy T3N0, T4N0 Surgery and Post op RT N+ Chemotherapy T4b, N3, M+ PALLIATION - Primarily RT Chemo CURATIVE 30. Management T1-2 => Either Surgery or Radiotherapy. T3-4 => Combination of chemoradiotherapy and Surgery. 31. Dr.Haris PS/ OMR39 Advantages Short time compliance Specimen available for HPE Helps in planning adjuvant treatment No radiation sequelae Disadvantages Tissue & functional loss Disfigurement Infection Bleeding Mortality 32. Radiation Therapy They have equal success in controlling T1 lesions. They are part of treatment Curative. Combination of therapy. Palliative. 33. Pros and Cons of Radiotherapy Provide better functional result with superior speech and swallowing. Disadvantage of altered taste,xerostomia and the protracted nature of treatment course. Requires atleast 6 weeks of treatment. Osteonecrosis of mandible. Newer technique of IMRT and brachytherapy reduces above side effects. 34. Chemotherapy Dr.Haris PS/ OMR42 Curative - Neoadjuvant (Induction) - Adjuvant - Concurrent: to treat micromets Palliative - Recurrence - Metastatic disease Drugs - Cisplatin, Methotrexate, 5 FU 35. Neck Dissection Selective neck dissection. Supraomhyoid neck dissection Central compartment neck dissection Posterior triangle dissectio Comprehensive neck dissection. Radical and modified radical neck dissection. 36. Prognostic factors Predictors of Poor prognosis: Increasing tumor thickness(>4mm) Poorly differentiated High grade tumors Perineural,Vascular and lymphatic invasion. DNA ploidy status such as aneuploid carry worst prognosis Verrucuous Ca has better one 37. Prognosis Stage 1: 80 90 % Stage 2: 70 80 % Stage 3: 30 50 % Stage 4: 20 30 %