Ca Tongue

ADVANCED LESIONS

Best managed by a combination of surgery and radiation

CANCER OF THE ORAL

An overview of managementByDr. M. Ashraf MD,MS,DNB(M Ch) SURGICAL ONCO.

THE LEGEND GOES IN

WEST INDIES

asked to get him the

best and the worst dishes.ORULA brought

dishes of ox tongue. WHY? asked OBTALA

‘Tell me, why did you choose tongue’ asked

‘A tongue is capable of doing such good’replied . ‘It can speak words of love and kindness. It can tell jokes and make people laugh, as well giving comfort to those in pain’

‘

Because, just as a tongue is capable of doing good, it is capable of immense evil’ said .

‘A tongue can spread lies, and inflict immense pain by uttering cruel words. It can even lead people to do wicked deeds.’

characteristics

Aggressive tumour High mortality Management improving Overall 5yr survival <50% Key to better survival…….?

PREDISPOSING FACTORS

Leukoplakia:

WHO 1978- White patches not characterised clinically and pathologically as any other disease

Sugar &Bancozy: Leukoplakia simplex Leukoplakia verrucosa Leukoplakia erosiva

Oral Cancer Screening



Malignant transformation

AT 3 yrs 31% disappeared 305 improved 25% unchanged 7.5% spread in oral cavity 6% malignant transformation

BANCOZY et al

CAUTION!!

White not always good!!

If u see white, stop n think:

“HISTORY HAS A HABIT OF REPEATING ITSELF”

ERYTHROPLKIA

WHO: red, velvety plaques not ascribable to any other condition

91% lesions contain severe dysplasia or ca

in situ or cancer as compared to leukoplakia (4.5% ca in situ)

Mashberg et al; Cancer

TONGUE CANCER

2nd common after lip Lateral border of middle third >2cm at first clinical examination(Conley et

al:Cancer) Posterior 3rd silent till late Metastasis to neck nodes more common >40% mets,base lesions 70% >20% bilateral mets

Near-Total Glossectomy

OVERVIEW OF TREATMENT

Tailored according to stage

T1 and T2: RT and SURGERY equally acceptable

Larger lesions are best managed by combined modality treatment

Comparative highlights

Early lesions: 5 yr survival for RT or SURGERY ranges 80%-90%

Local necrosis and bone exposure more with RT

Severe complications were observed in 9% at the university of Florida after RT.

ADVANTAGES OF SURGERY

Control of margins Histopathological assessment for

unfavorable characteristics Preserving the option of RT for second

primary (40% incidence. Hong et al: Cancer)

ADEQUATE MARGIN

How generous? Retained microscopic cancer? Prognostic implications of the microscopic

determinations of “adequacy” of local excision?

DIFFICULTIES

Criteria of positive or negative margins lack standardization

Effects of closeness or dysplasia on prognosis not systematically assessed

Reliabilities of measurement vary with the conditions of measurement

10% tumors resist surgical goal of free margins

WHAT WE ACHIEVE!!

Lesional tissue within 0.5 cm of margin is associated with 80% rate of recurrence

If the margin is negative,there is certainly no assurance of successful control

SURGICAL APPROACHS

Peroral excision Cheek flap Visor flap Mandibular swing

CASE 3 pre-op

CASE 3 per-op

PREOP PHOTO

MANAGEMENT OF NECK

Treatment of cervical lymphatics is recommended for virtually all patients

OS benefit is small but trend towards improved survival is seen

Selective ND levels 1-3 +/-4 is advised for N0 and selected N+ patients

RT is an alternative

CASE 3 per-op

MESSAGE

Look at your tongues!! If you don't------a surgeon would certainly do

the job for you!!!

BUT There will be no guarantee that your tongue

will remain in your mouth!!!

RECONSTRUCTION

Single stage immediate reconstruction is recommended.

Pedicled myocutaneous flaps long been used Free flap is most reliable. Ant mandibular defects---FREE flap Lat mandibular defect reconstruction

controversial

Near Total GlossectomyNear Total Glossectomy






DIFFICULTIES

No reliable method to assess 3D aspect of tumor extent and occult nodal mets

After presumed complete resection margin contains microscopic tumor--- What to do? RT should be given as there is a trend for improved survival.Reoperation is impractical in these cases

CT or MRI? Both equally reliable for soft tissue extent and bony involvement.

DIFFICULTIES AND CONTROVERSIES

Choice of treatment modality? Highly emotional and biased response!!! Radiation oncologist conveniently forgets about dental problems,necrosis,induration,fixation,fibrosis etc.

Management of clinically negative neck—treat or wait?

Extent of ND for early lesions?

DIFFICULTIES AND CONTROVERSIES

Induction chemotherapy or induction chemoradiation?

When lesion is close to mandible with no radiological evidence of gross involvement---mandibular resection or no resection,and to what extent,if yes?

For advanced lesions CCRT or conventional management?

MESSAGE

Whichever school of thought you profess allegiance to,doesn’t matter much as long as you don’t forget that:

“No site of head and neck cancer is more capricious with respect to clinical course than that of a SCC of anterior two thirds of tongue”

FOR PATIENCE

Health & Medicine

Ca Tongue