ORAL CAVITY

MALIGNANCY &
CARCINOMA OF
TONGUE
BINIL SHAJAN
BASIL PAULOSE
BHARATH LAL
CONDITIONS ASSOCIATED WITH
MALIGNANT TRANSFORMATION
• HIGH-RISK LESIONS
• Leucoplakia
• Erythroplakia
• Chronic hyperplastic candidiasis
• MEDIUM RISK LESIONS
• Oral submucous fibrosis
• Syphilitic glossitis
• Sideropenic dysphagia
• Leukoplakia : It is a white patch in the mucosa of the oral cavity that cannot be
characterized clinically or pathologically to any other disease.
The causes for leukoplakia are as follows:
• Smoking
• Spices
• Spirits have synergistic action with smoking
• Betel nut, and slaked lime with betel leaf and tobacco (pan) is eaten and
usually kept inside the cheek for many hours. Over the years, it brings about
chronic irritation of mucosa of the cheek and causes leukoplakia.
Types
1. Homogenous-uniform white patches with less malignant potential;
most common type
2. Nodular-fine nodules on the surface; more malignant potential.
3. Speckled leukoplakia-white flecks with fine nodules with an
atrophic erythematosus base; much higher potentiality for
malignancy. But it is less common.
4. Proliferative verrucous leukoplakia is rare but aggressive with 85%
malignant potential ; is common in elderly women; not associated
with tobacco use.
Features
• White or greyish
• It is usually painless and non-tender.
• 80% occur after the age of 40 years.
• Buccal mucosa and oral commissures are most common sites.
• Leukoplakia of long duration; leukoplakia in elderly; leukoplakia in
younger females; leukoplakia in floor of the mouth and tongue;
leukoplakia with induration, cracks and fissures are more likely to
turn into malignancy
• Biopsy confirms the diagnosis as well as rules out the carcinoma
Treatment
• Management of etiological factors
Pan chewing and smoking has to be stopped.
• Excision, if required skin grafting has to be done
• Medical management, Isotretinoin (13- cis-retinoic acid) can reverse
some cases of leukoplakia and possibly reduce the development of
squamous cell carcinoma.
 ERYTHROPLAKIA
• It is red velvety appearance of the mucosa which cannot characterise any
recognised condition.
• It is 17-20 times more potentially malignant than leukoplakia.
• Malignant transformation occurs in more than 50% of cases.
• Red colour is due to decreased keratin causing shining and prominence of
submucosal red vascularised connective tissue.
• It can be homogenous/speckled/granular or erythroplakia interspersed with
leukoplakia.
• Diagnosis is done by biopsy.
• Treatment Biopsy and surgical excision.
ORAL SUBMUCOSAL FIBROSIS
• This is supposedly due to use of pan masala, arecanut with or without
alcohol.
• Initially it produces ulceration of mucosa of the cheek.
These ulcers heal resulting in a dense submucous fibrosis, which
appear clinically firm to hard. It can affect the tongue also.
• Chances of malignancy are around 10-15%.
• Mouth opening may be restricted
Treatment
• Precipitating factors should be avoided
• Maintaining oral hygiene
• Local injection of dexamethasone (4 mg) with hyalase (1500 units)
biweekly for 10 weeks; vitamin and iron supplements.
• Surgical excision of the lesion with coverage of raw area using skin graft.
CARCINOMA OF
ORAL CAVITY
CARCINOMA OF BUCCAL MUCOSA

• CARCINOMA OF BUCCAL MUCOSA IS VERY COMMON IN INDIA DUE

TO THE HABIT OF KEEPING TOBACCO QUID IN THE CHEEK POUCH
PATHOLOGICAL TYPES
1. A non healing ulcer with slough on the centre of lesion.
2. An exophytic growth or a proliferative growth-VERRUCUOS
CARCINOMA
3. An infilterative lesion
CLINICAL FEATURES
• A non healing ulcer or cauliflower like growth.
• Edges are everted
• Induration clinically presents a hard feeling.Pathologically ,it is due to
fibrosis caused by malignancy.It is the diagnostic feature of squamous
cell carcinoma.
• Ulcer bleeds on touch.
• Fixity to the underlying structures such as mandible may
be present
• Surrounding area may also show induration.
• Evidence of leukoplakia may be present in the oral cavity.
• Trismus is due to involvement of pterygoid muscles and
masseter. This occurs when carcinoma buccal mucosa
extends into the retromolar trigone.
• Halitosis is very characteristic.
 COMPLICATIONS OF CARCINOMA
BUCCAL MUCOSA
1. Orocutaneous fistula
2. Trismus-It can be due to direct infiltration of pterygoid muscles or
masseter
3. Recurrent respiratory tract infection
4. Cancer cachexia.
GINGIVAL CANCER
- Early cases present as mucosal change in leukoplakia
- Loosening of tooth may be a presenting feature.
- Can present as bleeding and pain
- Bone involvement occurs early
- Spread to adjacent structures occurs early
TONGUE CANCER
TONGUE CANCER
Pathological types
1. Nonhealing ulcer, commonly on lateral border of tongue
in 60% of cases, with slough
2. A proliferative growth, with everted edge
3. Frozen tongue or indurated variety
In this variety, there is maximum induration and sometimes
it is more than the size of tumour. The tongue is converted
into a hard woody "mass".
4. Fissure variety: The tongue is indurated with deep fissure.
Clinical Presentations
• A bleeding ulcer
• Pain in the tongue is due to involvement of lingual nerve.
• Ankyloglossia is restricted mobility of the tongue
• Disarticulation-difficulty in talking
• Dysphagia is a common presentation from carcinoma of
posterior 113rd (in 20% cases).
• Foetor oris is due to infected necrotic growth.
• Bilateral massive enlargement of lower deep cervical nodes
CLINICAL EXAMINATION
• Inspection and palpation of the growth or the ulcer should
be described in the same manner as that of carcinoma
cheek. Typically, the ulcer bleeds on touch with central
slough. The edge, base and sun-ounding area are indurated.
•Carcinoma of the tongue and carcinoma of the penis are
two places in the body wherein induration can be much
more extensive than the primary growth or an ulcer.
• Digital palpation of posterior I/3rd of tongue should be
done with a glove.
•Test for mobility of the tongue.
- Forward protrusion-genioglossus. This is the muscle
commonly involved.
- Backward movement styloglossus
- Elevation-palatoglossus
-Depression-hyoglossus
•Bidigital palpation of the mandible should be done which
may show thickening
SPREAD OF ORAL CAVITY
MALIGNANCY
1. Local spread:
Once it involves the entire thickness of the
cheek it results in orocutaneous fistula. Involvement of mandible
results in sinus.
2. Lymphatic spread: Submandibular nodes and upper deep
cervical nodes get enlarged (Levels l and II). In 50% of
the cases, lymph node enlargement is due to infection and
remaining 50%, it is due to metastasis
 Metastatic deposits are hard in consistency, indurated and with or
without fixity. Significant oedema of face can occur due to lymphatic
spread
3. Blood spread:
It is very rare and it occurs late.
4.Perineural spread:
Along the inferior alveolar nerves may occur upto the skull base.
INVESTIGATION OF ORAL CAVITY
MALIGNANCY
1. Wedge biopsy from the edge of the ulcer is taken because
of the following reasons:
• Tumour cells are concentrated more in the growing edge ,
comparison with the normal tissues is possible.
• Centre of the ulcer has slough.
 Histopathological report shows squamous cell
carcinoma and in majority of the cases it is well differentiated.
2. Orthopantomography: X-ray of mandible to rule out
mandibular involvement
3. Chest X-ray to detect inhalation pneumonia.
4. FNAC of the lymph node.
5. Magnetic resonance imaging (MRI)
It is the investigation of choice to look for involvement
of{1} skull base, {2}brachial plexus,{3} spinal nerve roots and
{4}lymph nodes.
6.CECT :It is done when growth is infiltrating mandible.
TREATMENT OF ORAL CAVITY
MALIGNANCY
• Disease can be classified into early and advanced

EARLY DISEASE
T1 and T2 lesions
• T1, T2 lesions-surgery/RT
• T1 lesion near commissure-RT
• T2-exophytic and superficial-Surgery
• T2-deep-surgery is better
• Early disease-no nodes-surgery is better-no other
treatment is necessary.
• Early disease-positive lymph nodes-same modality to be
used for primary and secondary.
1. SURGERY
• 1. A small superficial ulcer (T 1, T2) is treated by wide
excision followed by split skin graft (SSG).
2. An infiltrative lesion is treated with wide excision followed
by a flap reconstruction. Usually, PMMC (pectoralis major
myocutaneous flap) is used
• PMMC flap: This is the most widely used flap now for head
and neck reconstruction. The flap is raised along with muscle
and an island of skin based on pectoral branch of
thoracoacromial artery. It is tunnelled under the skin of
chest wall and neck and brought to the area of the defect. It
has been described as the 'workhorse' for head and neck
Reconstruction
• Radial artery based flap is the workhorse of microvascular
reconstruction.
2. RADIOTHERAPY
Early lesions can be managed with radiotherapy (RT).
The advantage of RT is that it can preserve the organ and its function.
Disadvantage : No assurance of complete cure , Recurrence may occur
Indications for radiotherapy
1. T l and T2 lesions
2. Lesion near the commissure .
3. Patient not fit for surgery
4. Patient not willing for surgery
Types of Radiotherapy
1. External radiotherapy: Large total dose of 6000-8000
cGy units are given at the rate of 200 cGy units/day.
2. Interstitial radiotherapy is indicated in infiltrative small
lesions. Advantage of this method is minimal tissue
reaction.
Advanced Carcinoma
T3 and T4 lesions
•Surgery: T3 and T4 lesions require surgery as the main modality of the
treatment followed by postoperative radiotherapy.
•Most of the lesions require full thickness resection
leaving behind large defects. Such defects can be repaired using
myocutaneous flap.
SPECIAL CASES OF SURGERY
1. Carcinoma buccal mucosa fixed to the mandible:
Wide excision of the growth along with segmental resection of
the mandible or hemimandibulectomy is done depending
upon the infiltration of the tumour.
Very often, whole thickness of the cheek is lost which is reconstructed
by using PMMC flap
TYPES
• Segmental mandibulectomy: Indications
A. Clinical and radiological involvement of bone
B. To obtain wide margins
C. To facilitate reconstruction when one has to use
'bulky' PMMC flap
D. Excision of full thickness of cheek
• Marginal mandibulectomy: It can be done for
carcinoma floor of the mouth or tongue. In this removal
of either inner or outer table of the mandible or excising the superior
rim of the mandible. However, in large lesions, it is better not to do
marginal mandibulectomy.
• Hemimandibulectomy: Very advanced lesion may
necessitate removal of mandible
2. Orocutaneous fistula is treated by wide excision which
refers to removal of the entire thickness of the cheek along
with the growth.
Reconstruction is done by using PMMC flap. Radiotherapy
should not be given as it results in persistence of fistula
3. Carcinoma of the buccal mucosa with lymph nodes:
Along with the primary, submandibular nodes and upper
deep cervical nodes (Levels I, II and III) are removed,
along with submandibular salivary gland. This is called
supraomohyoid block dissection.
4. Carcinoma of buccal mucosa with fixed lymph nodes:
Both primary lesion and lymph nodes should be treated
by radiotherapy and reassessment done after 3-4 weeks.
If residual glands persist or if the glands become mobile,
neck dissection can be done at a later date
TREATMENT OF TONGUE CANCER

• Carcinoma of the tongue is managed similar to a cancer in the

oral cavity.
VARIOUS TYPES OF SURGERY

1. Carcinoma in situ:
•Wide excision with 1 cm margin and a depth of 1 cm is
sufficient.
•Reconstruction of the tongue is not necessary.
2. Partial glossectomy is indicated when the lesion is less than 2 cm (Tl ) and
confined to the lateral border of the tongue.
3. Hemiglossectomy refers to removal of around 50% of the
tongue. This is indicated in a radio-residual tumour, radiorecurrent
tumour or where radiotherapy facilities are not
available
 4. Total glossectomy:
•very extensive growth
Involving the entire tongue are given radiotherapy initially,
to reduce the size of the tumour.
•Surgery can then be undertaken
5. Commando's operation: This is indicated when
carcinoma of tongue is fixed to the mandible with
infiltration of the floor of the mouth.
• Hemiglossectomy with hemimandibulectomy, removal of the floor of
the mouth and radical neck dissection is described as Commando's
operation
NECK DISSECTION
• It is a standardised dissection of cervical nodes by applying
anatomical and oncological principles including removal of
surrounding fibrofatty tissue from various compartments of the neck

INDICATIONS
• Carcinoma tongue
• Carcinoma of floor of mouth
• Malignant melanoma
• Metastatic lymph node from pharynx and upper oesophagus
Contraindications
•Fixed nodes ,evidence of distant metastasis
•Untreatable primary cancer

Types
1.Classical radical neck dissection
removal of level I-V nodes + internal jugular vein , sternomastoid +
spinal accessory nerve
2. Modified radical neck dissection
Type 1 :
• preserve one structure : spinal accessory nerve
• classically done for squamous cell carcinoma of upper aerodigestive tract
with clinically positive neck dissection
Type 2
•Preserve two structures:Spinal accessory and IJV
Type 3
•Preserve three structures: spinal accessory, sternocleidomastoid,and IJV
• 3. Selective neck dissection
Any of the lymphatic compartments are preserved
Few examples are : Supraomohyoid dissection
Lateral neck dissection
Posterolateral neck dissection
Causes of death in carcinoma tongue
l . Recurrent aspirational pneumonia
2. Gross local recurrence, fungation, ulceration, cachexia.
3. Uncontrolled haemorrhage from growth
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