Premalignant Lesions and Carcinoma of the Tongue: Diagnosis, Staging, and Treatment Strategies

Premalignant Conditions Of The Oral Cavity

1. Pre-malignantlesions are defied as“A morphologically altered tissue in which cancer is more likely to occur than its apparently normal counterpart”.

Following are the premalignant lesions:

• Leukoplakia
• Erythroplakia
• Mucosal changes associated with smoking habits
• Carcinoma in situ
• Bowen disease
• Actinic keratosis, chelitis and elastosis.
  features of premalignant lesions of oral cavity.

“What Are Premalignant Lesions Of The Tongue”

2. Carcinoma of Tongue (anterior two-third) Stage II.

Carcinoma of Tongue Clinical Features

• Painless ulcer or swelling on the tongue which later on may become painful.
  Pain is present in the tongue due to infection or ulceration or due to involvement of lingual nerve.
• Salivation is excessive and is often blood stained.
• Visible ulcer can be seen on anterior two-third of tongue.
  Ulcer can bleed on touch; edge, base and surrounding areas are indurated.
  Often indurated area is more extensive than primary tumor.
  Edges are everted.
  Ulcer may cross the midline and extend to the flor or mouth/alveolus/mandible.
• Fetor oris is due to infected necrotic growth.
• Ankyloglossia restricted mobility of the tongue. It is due to infiltration of the mouth or mandible.
• Disarticulation—difficulty in talking is due to disability of the tongue to move freely.
• Presence of palpable lymph nodes in the neck which are hard, nodular and get fired to underlying tissues in advanced stages.

“Causes Of Tongue Carcinoma”

Carcinoma of Tongue Investigations

• Biopsy is the golden standard to identify the carcinoma of tongue. Biopsy of the lesional margin is done and histopathological evaluation is done.
  Broader classifiation histologically divides oral cancer in various stages which are:
• Well-diffrentiated squamous cell carcinoma
• Moderately diffrentiated squamous cell carcinoma
• Poorly diffrentiated squamous cell carcinoma
• FNAC of lymph nodes
• CT scan to see the status of lymph node secondaries.
• MRI to assess extent of primary tumor
• Chest X-ray to see bronchopneumonia
• Orthopantomogram

Carcinoma of Tongue Treatment

Stage II tumor means T2N0M0, i.e. Tumor more than 2 cm but not more than 4 cm in its greatest dimensions.

There is no regional lymph node metastasis and no distant metastasis.

So following treatment can be done.

“Symptoms Of Tongue Cancer”

Carcinoma of Tongue Surgery

• Wide excision with l cm clearance in margin and depth is done in tumor less than l cm in size or in carcinoma in situ.
  Laser (CO2/diode) can be used.
• Tumor between 1–2 cm in size, partial glossectomy is done with 2 cm clearance from the margin with removal of l/3rd
  of anterior two-third of the tongue.
• Tumor larger than 2 cm, hemiglossectomy is done with removal of anterior 2/3rd of tongue on one side up to sulcus terminalis.
• Raw area in these procedures can be left alone when area is wide allowing it to granulate and heal by epithelialization.
  lf area is small like in wide excision it can be closed by primary suturing. Wide raw area can also be covered with
  PMMF or quilted split-skin graft.

“The Role Of Biopsies In Detecting Tongue Carcinoma”

• Larger primary tumor can be given preoperative 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 junctional 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.
• Wide excision is done when growth is in the tip of the tongue.
• Reconstruction of tongue and other area after surgery: By deltopectoral flap, forehead flap, pectoralis major muscle flap, skin grafting.
• Prophylactic block dissection is becoming popular at present.

“Risk Factors For Developing Tongue Cancer”

Carcinoma of Tongue Radiotherapy

• In small primary tumor—brachytherapy using caesium or iridium needles.
• In large primary tumor initial radiotherapy is given to reduce the tumor size so that resection will be bettr later.
• Advanced primary, as well as secondaries in neck, are controlled by palliative external radiotherapy.
• Postoperative radiotherapy is given in large tumors to reduce the chances of relapse.

“Understanding The Causes Of Tongue Carcinoma”

Carcinoma of Tongue Chemotherapy

• It is given in postoperative period and 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 be given orally also.