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Squamous Carcinoma of the Oral Tongue Squamous cell carcinoma of the oral tongue represents one of the more common malignancies encountered by the general otolaryngologist as well as by one specializing in head and neck surgery. In the management of the early lingual cancers, a wide variety of therapuetic options have been advocated in the literature, and in addition to planning the treatment of the primary neoplasm, management of the neck must be considered as well. The dorsal aspect of the tongue may be thought of as divided into thirds. The anterior two thirds is known as the oral tongue, and it is this portion that is mobile. The oral tongue is demarcated from the posterior one third, or base of the tongue by the circumvallate papillae. Just posterior to these papillae is the sulcus terminalis, the embryologic dividing line between the structures of the first branchial arch (the oral tongue) and those deriving from the second, third and fourth branchial arches (the tongue base). The oral tongue is closely related anatomically to the tonsillar pillars posterolaterally, and the floor of the mouth inferiorly. The tongue is a muscular organ, composed of both extrinsic and intrinsic muscles. The extrinsic muscles serve primarily to change the position of the tongue and thus attach outside of the lingual body. The intrinsic muscles do not attach outside of the tongue and serve to change the shape of the lingual surface. Lymphatics from the most anterior aspect of the tongue drain into both the submental nodes as well as to the lower jugular nodes. The lateral portions drain into the submandibular nodes as well as to the upper and middle jugular lymphatics. The central tongue may drain into any of these regions and may also drain bilaterally. It is important to note that the more anteriorly a carcinoma is located, the higher the probability of involvement of the lowest level of jugular nodes. Lingual carcinomas may appear as an exophytic mass, an infiltrative lesion , or as a painful nonhealing ulcer, usually on the lateral aspect of the tongue. However patients may occasionally be seen with a painless mass in the substance of the tongue, or areas of leukoplakia or of erythroplasia may be noted. Ear pain is also a frequent presenting complaint, owing to the innervation by the auriculotemporal and lingual nerves, both branches of the trigeminal. Smoking, alcohol, chronic trauma, and poor dental hygiene, the usual predisposing factors implicated in cancers arising elsewhere in the oral cavity, are also associated with cancers of the oral tongue, although some suggest that the linkage is not nearly as strong. Males are more commonly affected than females, usually in the fifth or sixth decade. Cancers of the oral tongue as well as the floor of the mouth have been noted to be quite common in India, attributed to the local custom of chewing the Betel leaf. Several reports may also be found of oral tongue carcinomas in teenagers and young adults. Often, there are no apparent risk factors in this population and some reports suggest that the cancers behave more aggressively in this group. The TNM staging system provides a method of classification for these cancers based on primary tumor size and the presence of regional or distant metastases. Stages I and II denote cancers which have not spread clinically beyond the primary site. Stage I disease (T1N0) is widely reported to be effectively treated by either surgical excision or radiotherapy, although the morbidity of radiating the oral cavity must be considered. Adequate surgical margins are crucial at the initial excision, and may be difficult to obtain later with contraction of the musculature into the substance of the tongue. The wound may be closed primarily, covered with a skin graft, or left to heal by secondary intention. The bolster used with a skin graft may necessitate a tracheostomy. Treatment of the neck is a highly controversial point, but many authors feel that elective treatment of the neck is indicated even for T1 neoplasms based on the incidence of occult metastases, 20-33% in most series, as well as the poor results with a later salvage procedure. Most authors advocate elective treatment of the neck for stage II disease (T2N0) for the same reasons, and the incidence of occult metastases in this group is even higher. Supraomohyoid neck dissection is often the procedure of choice for management of the clinically negative neck, with radiation being reserved for those patients with lymphatic involvement, especially if there is evidence of capsular invasion. The problem of understaging has been frequently cited in reference to carcinomas of the oral tongue, and reports may be found addressing specific factors which may indicate those patients with early lesions most likely to harbor occult metastases, and thus be the most likely to benefit from prophylactic treatment of the neck. Such factors as depth of penetration, histologic grade, perineural or perivascular invasion have all been investigated but none are widely accepted to have reliable prognostic value. There is less controversy concerning the management of stage III disease, a designation signifying the presence of clinical neck involvement. As with stage IV (massive primary or neck disease), combined surgery and radiation are most often employed, and adequate removal of the primary lesion will frequently necessitate sacrifice of a portion of the mandible as a composite resection. In the past, suggestions were made that carcinoma of the oral cavity was less aggressive than its counterpart in the tongue base, however this is no longer felt to be true. Historically the poor survival of patients with cancer in the base of the tongue is more likely a reflection of their later presentation and diagnosis. Carcinomas of the oral tongue have a notorious tendency for early lymphatic spread, and optimal management of these early lesions requires effective removal of the primary neoplasm as well as consideration of elective treatment of the neck. Case Presentation A 50-year-old white male presented to the V.A. Otolaryngology Clinic with a three month history of a painful right tongue lesion. He had a 40 pack a year smoking history and consumed a substantial amount of alcohol on a daily basis. Examination in the clinic disclosed a 3 cm ulcerated lesion of the right lateral tongue, as well as a 2 cm firm mass in the right mid jugular region. Biopsy of the tongue lesion demonstrated moderately well differentiated squamous carcinoma. The patient underwent partial glossectomy and a modified radical neck dissection, followed by external beam radiation. He has remained free of disease since that time. Bibliography Americam Joint Commission on Cancer: Manual for the Staging of Cancer, Third Ed. Philadelphia, Lippincott, 1988. Bailey BJ (ed): Surgery of the Oral Cavity. Chicago, Year Book Medical Publishers, 1989. Bradfield JS, Scruggs RP: Carcinoma of the mobile tongue: Incidence of cervical metastasies in early lesions related to the method of primary treatment. Laryngoscope 93:1332-1336, 1983. Calery CD, Spiro RH, Strong EW: Changing trends in the management of squamous carcinoma of the tongue. Am J Surg 148:449-454, 1984. Decroix Y, Ghossein NA: Experience of the Curie Institute in treatment of cancer of the mobile tongue. Treatment policies and results. Cancer 47:496-502, 1981. 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Teichgraeber JF, Clairmont AA: The incidence of occult metastases for cancer of the oral tongue and floor of mouth: treatment rationale. Head Neck Surg 7:15-21, 1984. Usenius T, Karja J, Collan Y: Squamous carcinoma of the tongue in children. Cancer 60:236-239, 1987. White D, Byers RM: What is the preferred method of treatment of squamous carcinoma of the tongue? Am J Surg 140:553-555, 1980. Grand Rounds Archive | Department Home page BCM Public | BCM Intranet | Privacy Notices | Contact BCM | BCM Site Map | ©2001-2006 Baylor College of Medicine
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