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Carcinoma tongue
Carcinoma tongue
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  1. 1. ADVANCED LESIONS <ul><li>Best managed by a combination of surgery and radiation </li></ul>
  2. 2. CANCER OF THE ORAL An overview of management By Dr. M. Ashraf MD,MS,DNB(M Ch) SURGICAL ONCO. TONGUE
  3. 3. <ul><li>THE LEGEND GOES IN </li></ul><ul><li>WEST INDIES </li></ul>
  4. 4. <ul><li> asked to get him the </li></ul><ul><li>best and the worst dishes.ORULA brought </li></ul><ul><li>dishes of ox tongue. </li></ul><ul><li>WHY? asked OBTALA </li></ul>OBATALA ORULA OBTALA ORULA
  5. 5. <ul><ul><li>‘ Tell me, why did you choose tongue’ </li></ul></ul><ul><ul><li>asked </li></ul></ul><ul><ul><li>‘ A tongue is capable of doing such good’ </li></ul></ul><ul><ul><li>replied . ‘It can speak </li></ul></ul><ul><ul><li>words of love and kindness. It can tell </li></ul></ul><ul><ul><li>jokes and make people laugh, as well </li></ul></ul><ul><ul><li>giving comfort to those in pain’ </li></ul></ul>OBATALA ORULA
  6. 6. <ul><li>‘ </li></ul><ul><li>Because, just as a tongue is capable of doing good, it is capable of immense evil’ said . </li></ul><ul><li>‘ A tongue can spread lies, and inflict immense pain by uttering cruel words. It can even lead people to do wicked deeds.’ </li></ul>ORULA inflict immense pain
  7. 7. characteristics <ul><li>Aggressive tumour </li></ul><ul><li>High mortality </li></ul><ul><li>Management improving </li></ul><ul><li>Overall 5yr survival <50% </li></ul><ul><li>Key to better survival…….? </li></ul>
  8. 8. PREDISPOSING FACTORS <ul><li>Leukoplakia: </li></ul><ul><li>WHO 1978- White patches not characterised clinically and pathologically as any other disease </li></ul><ul><li>Sugar &Bancozy: </li></ul><ul><li>Leukoplakia simplex </li></ul><ul><li>Leukoplakia verrucosa </li></ul><ul><li>Leukoplakia erosiva </li></ul>
  9. 9. Oral Cancer Screening
  10. 10. Oral Cancer Screening
  11. 11. Oral Cancer Screening
  12. 12. Malignant transformation <ul><li>AT 3 yrs </li></ul><ul><li>31% disappeared </li></ul><ul><li>305 improved </li></ul><ul><li>25% unchanged </li></ul><ul><li>7.5% spread in oral cavity </li></ul><ul><li>6% malignant transformation </li></ul><ul><li>BANCOZY et al </li></ul>
  13. 13. CAUTION!! <ul><li>White not always good!! </li></ul><ul><li>If u see white, stop n think: </li></ul><ul><li>“HISTORY HAS A HABIT OF REPEATING ITSELF” </li></ul>
  14. 14. ERYTHROPLKIA <ul><li>WHO: red, velvety plaques not ascribable to any other condition </li></ul><ul><li>91% lesions contain severe dysplasia or ca in situ or cancer as compared to leukoplakia (4.5% ca in situ) </li></ul><ul><li>Mashberg et al; Cancer </li></ul>
  15. 15. TONGUE CANCER <ul><li>2 nd common after lip </li></ul><ul><li>Lateral border of middle third </li></ul><ul><li>>2cm at first clinical examination(Conley et al:Cancer) </li></ul><ul><li>Posterior 3 rd silent till late </li></ul><ul><li>Metastasis to neck nodes more common </li></ul><ul><li>>40% mets,base lesions 70% </li></ul><ul><li>>20% bilateral mets </li></ul>
  16. 16. Near-Total Glossectomy
  17. 17. OVERVIEW OF TREATMENT <ul><li>Tailored according to stage </li></ul><ul><li>T1 and T2: RT and SURGERY equally acceptable </li></ul><ul><li>Larger lesions are best managed by combined modality treatment </li></ul>
  18. 18. Comparative highlights <ul><li>Early lesions: 5 yr survival for RT or SURGERY ranges 80%-90% </li></ul><ul><li>Local necrosis and bone exposure more with RT </li></ul><ul><li>Severe complications were observed in 9% at the university of Florida after RT. </li></ul>
  19. 19. ADVANTAGES OF SURGERY <ul><li>Control of margins </li></ul><ul><li>Histopathological assessment for unfavorable characteristics </li></ul><ul><li>Preserving the option of RT for second primary (40% incidence. Hong et al: Cancer) </li></ul>ADVANTAGES OF SURGERY ADVANTAGES OF SURGERY
  20. 20. ADEQUATE MARGIN <ul><li>How generous? </li></ul><ul><li>Retained microscopic cancer? </li></ul><ul><li>Prognostic implications of the microscopic determinations of “adequacy” of local excision? </li></ul>
  21. 21. DIFFICULTIES <ul><li>Criteria of positive or negative margins lack standardization </li></ul><ul><li>Effects of closeness or dysplasia on prognosis not systematically assessed </li></ul><ul><li>Reliabilities of measurement vary with the conditions of measurement </li></ul><ul><li>10% tumors resist surgical goal of free margins </li></ul>
  22. 22. WHAT WE ACHIEVE!! <ul><li>Lesional tissue within 0.5 cm of margin is associated with 80% rate of recurrence </li></ul><ul><li>If the margin is negative,there is certainly no assurance of successful control </li></ul>
  23. 23. SURGICAL APPROACHS <ul><li>Peroral excision </li></ul><ul><li>Cheek flap </li></ul><ul><li>Visor flap </li></ul><ul><li>Mandibular swing </li></ul>
  24. 24. CASE 3 pre-op
  25. 25. CASE 3 per-op
  26. 26. PREOP PHOTO
  27. 32. MANAGEMENT OF NECK <ul><li>Treatment of cervical lymphatics is recommended for virtually all patients </li></ul><ul><li>OS benefit is small but trend towards improved survival is seen </li></ul><ul><li>Selective ND levels 1-3 +/-4 is advised for N0 and selected N+ patients </li></ul><ul><li>RT is an alternative </li></ul>
  28. 33. CASE 3 per-op
  29. 36. MESSAGE <ul><li>Look at your tongues!! </li></ul><ul><li>If you don't------a surgeon would certainly do the job for you!!! </li></ul><ul><li>BUT </li></ul><ul><li>There will be no guarantee that your tongue will remain in your mouth!!! </li></ul>
  30. 37. RECONSTRUCTION <ul><li>Single stage immediate reconstruction is recommended. </li></ul><ul><li>Pedicled myocutaneous flaps long been used </li></ul><ul><li>Free flap is most reliable. </li></ul><ul><li>Ant mandibular defects---FREE flap </li></ul><ul><li>Lat mandibular defect reconstruction controversial </li></ul>
  31. 38. Near Total Glossectomy
  32. 39. Near Total Glossectomy
  33. 40. Near Total Glossectomy
  34. 41. Near Total Glossectomy
  35. 42. Near Total Glossectomy
  36. 44. Near Total Glossectomy
  37. 45. DIFFICULTIES <ul><li>No reliable method to assess 3D aspect of tumor extent and occult nodal mets </li></ul><ul><li>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 </li></ul><ul><li>CT or MRI? Both equally reliable for soft tissue extent and bony involvement. </li></ul>
  38. 46. DIFFICULTIES AND CONTROVERSIES <ul><li>Choice of treatment modality? Highly emotional and biased response!!! Radiation oncologist conveniently forgets about dental problems,necrosis,induration,fixation,fibrosis etc. </li></ul><ul><li>Management of clinically negative neck—treat or wait? </li></ul><ul><li>Extent of ND for early lesions? </li></ul>
  39. 47. DIFFICULTIES AND CONTROVERSIES <ul><li>Induction chemotherapy or induction chemoradiation? </li></ul><ul><li>When lesion is close to mandible with no radiological evidence of gross involvement---mandibular resection or no resection,and to what extent,if yes? </li></ul><ul><li>For advanced lesions CCRT or conventional management? </li></ul>
  40. 48. MESSAGE <ul><li>Whichever school of thought you profess allegiance to,doesn’t matter much as long as you don’t forget that: </li></ul><ul><li>“ 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 ” </li></ul>