Tongue neoplasm

Synonyms

2

Overview

Tongue cancer is one type of cancer of the internal oral region;

Symptoms

Skin lesion, lump, or ulcer that do not resolve in 14 days located:

  • On the tongue, lip, or other mouth areas
  • Usually small
  • Most often pale colored, may be dark or discolored
  • Early sign may be a white patch (leukoplakia) or a red patch (erythroplakia) on the soft tissues of the mouth
  • Usually painless initially
  • May develop a burning sensation or pain when the tumor is advanced
  • Behind the wisdom tooth
  • Even behind the ear

Additional symptoms that may be associated with this disease: 

  • Tongue problems (moving it)
  • Swallowing difficulty
  • Mouth sores
  • Pain and paraesthesia are late symptoms.

Causes

* Aphthous stomatitis –Idiopathic –Recurrent, shallow, painful, spontaneously resolving oral ulcers * Herpes stomatitis –Due to a primary outbreak of HSV-1 –Severe gingivostomatitis with pain, redness, and erosions around the gum line –Recurrent oral HSV (“cold sores”) often occur at the lip border –Stress, sun exposure, and many other factors contribute to flare-ups * Self-limited viral disease (e.g., herpangina, hand-foot-mouth disease) –Most often seen in children –Prodrome of malaise and fever followed by a 5–10 day outbreak of oropharyngeal erosions or vesicles is common o Chemotherapy drugs (especially 5-FU and methotrexate) o Squamous cell carcinoma should always be considered if a nonhealing ulcer or oral erosion is noted o Bullous diseases (e.g., pemphigoid, pemphigus, lichen planus) –Recurrent painful oral ulcers and erosions –Evaluate for other skin rashes suggestive of these disorders + Behçet syndrome –Uncommon but well-known cause of oral ulcers –Patients must exhibit other symptoms (e.g., uveitis, CNS problems, GI complaints, genital ulcers) before this diagnosis can be made + Allergic contact dermatitis to amalgams in dental work may result in buccal tenderness + Erythema multiforme (Stevens-Johnson syndrome) –Characterized by oral ulcers, ocular involvement, and simultaneous targetoid, erythematous, or bullous skin lesions –May be triggered by HSV infection, Mycoplasma infection, or drugs (e.g., phenytoin, sulfonamides) * Primary syphilis –Painless chancre * Agranulocytosis or leukopenia * Histoplasmosis (especially in immunosuppressed patients)

Prevention

  • Oral hygiene
  • Good nutrition
  • No excessive tobacco and alcohol consumption

Diagnosis

An examination of the mouth by the health care provider or dentist shows a visible and/or palpable (can be felt) lesion of the lip, tongue, or other mouth area. The lateral/ventral sides of the tongue are the most common sites for intraoral SCC. As the tumor enlarges, it may become an ulcer and bleed. Speech/talking difficulties, chewing problems, or swallowing difficulties may develop. A feeding tube is often necessary to maintain adequate nutrition. This can sometimes become permanent as eating difficulties can include the inability to swallow even a sip of water. The doctor can order some special investigations which may include a chest x-ray, CT or MRI scans, and tissue biopsy.

There are a variety of screening devices that may assist dentists in detecting oral cancer, including the Velscope, Vizilite Plus and the identafi 3000. There is no evidence that routine use of these devices in general dental practice saves lives. However, there are compelling reasons to be concerned about the risk of harm this device may cause if routinely used in general practice. Such harms include false positives, unnecessary surgical biopsies and a financial burden on the patient. While a dentist, physician or other health professional may suspect a particular lesion is malignant, there is no way to tell by looking alone - since benign and malignant lesions may look identical to the eye. A non-invasive brush biopsy (BrushTest) can be performed to rule out the presence of dysplasia (pre-cancer) and cancer on areas of the mouth that exhibit an unexplained color variation or lesion. The only definitive method for determining if cancerous or precancerous cells are present is through biopsy and microscopic evaluation of the cells in the removed sample. A tissue biopsy, whether of the tongue or other oral tissues and microscopic examination of the lesion confirm the diagnosis of oral cancer or precancer. There are six common species of bacteria found at significantly higher levels in the saliva of patients with oral squamous cell carcinoma (OSCC) than in saliva of oral-free cancer individuals. Three of the six, C. gingivalis, P. melaninogenica, and S. mitis, can be used as a diagnostic tool to predict more than 80% of oral cancers.

Prognosis

  • Postoperative disfigurement of the face, head and neck
  • Complications of radiation therapy, including dry mouth and difficulty swallowing
  • Other metastasis (spread) of the cancer
  • Significant weight loss

Prognosis depends on stage and overall health. Grading of the invasive front of the tumor is a very important prognostic parameter

Treatment

Surgical excision (removal) of the tumor is usually recommended if the tumor is small enough, and if surgery is likely to result in a functionally satisfactory result. Radiation therapy with or without chemotherapy is often used in conjunction with surgery, or as the definitive radical treatment, especially if the tumour is inoperable. Surgeries for oral cancers include:

  • Maxillectomy (can be done with or without orbital exenteration)
  • Mandibulectomy (removal of the mandible or lower jaw or part of it)
  • Glossectomy (tongue removal, can be total, hemi or partial)
  • Radical neck dissection
  • Mohs surgery or CCPDMA
  • Combinational, e.g. glossectomy and laryngectomy done together
  • Feeding tube to sustain nutrition

Owing to the vital nature of the structures in the head and neck area, surgery for larger cancers is technically demanding. Reconstructive surgery may be required to give an acceptable cosmetic and functional result. Bone grafts and surgical flaps such as the radial forearm flap are used to help rebuild the structures removed during excision of the cancer. An oral prosthesis may also be required. Most oral cancer patients depend on a feeding tube for their hydration and nutrition. Some will also get a port for the chemo to be delivered. Many oral cancer patients are disfigured and suffer from many long term after effects. The after effects often include fatigue, speech problems, trouble maintaining weight, thyroid issues, swallowing difficulties, inability to swallow, memory loss, weakness, dizziness, high frequency hearing loss and sinus damage.

Survival rates for oral cancer depend on the precise site, and the stage of the cancer at diagnosis. Overall, 2011 data from the SEER database shows that survival is around 57% at five years when all stages of initial diagnosis, all genders, all ethnicities, all age groups, and all treatment modalities are considered. Survival rates for stage 1 cancers are approximately 90%, hence the emphasis on early detection to increase survival outcome for patients. Similar survival rates are reported from other countries such as Germany.

Following treatment, rehabilitation may be necessary to improve movement, chewing, swallowing, and speech. Speech and language pathologists may be involved at this stage.

Chemotherapy is useful in oral cancers when used in combination with other treatment modalities such as radiation therapy. It is not used alone as a monotherapy. When cure is unlikely it can also be used to extend life and can be considered palliative but not curative care. Biological agents, such as Cetuximab have recently been shown to be effective in the treatment of squamous cell head and neck cancers, and are likely to have an increasing role in the future management of this condition when used in conjunction with other established treatment modalities.

Treatment of oral cancer will usually be by a multidisciplinary team, with treatment professionals from the realms of radiation, surgery, chemotherapy, nutrition, dental professionals, and even psychology all possibly involved with diagnosis, treatment, rehabilitation, and patient care.