tongue carcinoma

Dr sumer yadavDr sumer yadav

INTRODUCTIONINTRODUCTION

ORAL CANCER IS FIFTH MOST COMMON ORAL CANCER IS FIFTH MOST COMMON

MALIGNANCY GLOBALLY.MALIGNANCY GLOBALLY.

WESTERN WORLD # 2 TO 4 % OF WESTERN WORLD # 2 TO 4 % OF

MALIGNANT TUMORS.MALIGNANT TUMORS.

ASIA # NOT LESS THAN 40%ASIA # NOT LESS THAN 40%

RATIO OF MEN & WOMEN 3 : 1.RATIO OF MEN & WOMEN 3 : 1.

APPROX AGE > 60 YEARSAPPROX AGE > 60 YEARS

SOLID CONICAL MUSCULAR ORGAN, COVERED BY SOLID CONICAL MUSCULAR ORGAN, COVERED BY MUCOUS MEMBRANE, PRESENT IN ORAL CAVITY & MUCOUS MEMBRANE, PRESENT IN ORAL CAVITY & OROPHARYNX.OROPHARYNX.

ANT 2/3 ORAL TONGUE – FREELY MOBILE & ANT. ANT 2/3 ORAL TONGUE – FREELY MOBILE & ANT. TO CIRCUMVALLATE PAPILLAETO CIRCUMVALLATE PAPILLAE

POST 1/3 – BASE TONGUE – POST TO CIRCUM POST 1/3 – BASE TONGUE – POST TO CIRCUM VALLATE PAPILLAE & PALATOGLOSSAL ARCHVALLATE PAPILLAE & PALATOGLOSSAL ARCH

ANATOMIC REGION – TIP, LATERAL BORDER, ANATOMIC REGION – TIP, LATERAL BORDER, DORSUM & UNDER SURFACEDORSUM & UNDER SURFACE

EXTRINSIC & INTRINSIC MUSCLES ARE PRESENT EXTRINSIC & INTRINSIC MUSCLES ARE PRESENT SYMMETRICALLY SYMMETRICALLY

ANATOMYANATOMY

IT HELP IN MASTICATION, DEGLUTITION & IT HELP IN MASTICATION, DEGLUTITION & SPEECHSPEECH

RELATIVELY AVASCULAR MIDLINE - RELATIVELY AVASCULAR MIDLINE - MARKED BY MEDIAN FIBROUS SEPTUMMARKED BY MEDIAN FIBROUS SEPTUM

LINGUAL ARTRY – ECA AT Gr CORNU OF LINGUAL ARTRY – ECA AT Gr CORNU OF HYOID BONE HYOID BONE

DEEP VEIN – LINGUAL VEIN – IJVDEEP VEIN – LINGUAL VEIN – IJV NERVE SUPPLY – NERVE SUPPLY –

A. MOTORA. MOTOR– ALL MUSCLE – HYPOGLOSSAL NERVEALL MUSCLE – HYPOGLOSSAL NERVE– PALATOGLOSSAL – CRANIAL PART OF PALATOGLOSSAL – CRANIAL PART OF

SAN SAN

B. SENSORY B. SENSORY

– ANT 2/3 – LINGUAL NERVE & CORDA TYNPANIANT 2/3 – LINGUAL NERVE & CORDA TYNPANI

– POST 1/3 & CIRCUMVALLETE PAPILLAE – IXPOST 1/3 & CIRCUMVALLETE PAPILLAE – IXTHTH

NERVE.NERVE.

LYMPHATIC DRAINAGELYMPHATIC DRAINAGE

– ARISES FROM SUBMUCOSAL PLEXUSARISES FROM SUBMUCOSAL PLEXUS

– APICALSET – TIP & FRENULUM – SUBMENTALAPICALSET – TIP & FRENULUM – SUBMENTAL

– MARGINAL SET – SIDE OF TONGUE – MARGINAL SET – SIDE OF TONGUE –

SUBMANDIBULARSUBMANDIBULAR

– CENTRAL SET – DORSUM – JUGULODIAGASTRIC & CENTRAL SET – DORSUM – JUGULODIAGASTRIC &

OMOHYOIDOMOHYOID

– BASAL SET – POST 1/3 - JUGULODIAGASTRIC & BASAL SET – POST 1/3 - JUGULODIAGASTRIC &

OMOHYOIDOMOHYOID

IN MIDLINE FREE DECUSSATING OF LYMPHATIC IN MIDLINE FREE DECUSSATING OF LYMPHATIC

OCCUR & THEY PASSES BILATERALLYOCCUR & THEY PASSES BILATERALLY

TIP OF TONGUE – RICHEST LYMPHATIC TIP OF TONGUE – RICHEST LYMPHATIC DRAINAGEDRAINAGE

PRINCIPAL NODE– JUGULO OMOHYOIDPRINCIPAL NODE– JUGULO OMOHYOID

CARCINOMA TONGUE IS THE SECOND CARCINOMA TONGUE IS THE SECOND MOST COMMON SITE OF ORAL CA AFTER MOST COMMON SITE OF ORAL CA AFTER LIPLIP

SITE WISE INCIDENCE :-SITE WISE INCIDENCE :- – MIDDLE 1/3 OF LATERAL BORDER OF TONGUE MIDDLE 1/3 OF LATERAL BORDER OF TONGUE

- 47% - COMMONEST SITE - 47% - COMMONEST SITE POST 1/3 -20% POST 1/3 -20% TIP - 15% TIP - 15%

– VENTRAL SURFACE & FRENULUM - 9%VENTRAL SURFACE & FRENULUM - 9%

– DORSUM - 6.5%DORSUM - 6.5%

– FACIO – LINGUAL - 6%FACIO – LINGUAL - 6%

AGE OF PRESENTATION = 60 YEARSAGE OF PRESENTATION = 60 YEARS

MEN > WOMEN MEN > WOMEN

ETIOLOGYETIOLOGYTOBACCO : TOBACCO : 90% OF PATIENTS WITH CANCER USE 90% OF PATIENTS WITH CANCER USE

TOBACCO.TOBACCO. RISK OF CARCINOMA INCREASES WITH RISK OF CARCINOMA INCREASES WITH

AMOUNT OF TOBACCO USED & DURATION OF AMOUNT OF TOBACCO USED & DURATION OF HABIT.HABIT.

EXPOSURE TO TOBACCO CAUSES EXPOSURE TO TOBACCO CAUSES PROGRESSIVE SEQUENTIAL MORPHOLOGIC PROGRESSIVE SEQUENTIAL MORPHOLOGIC CHANGES OF MUCOSA LEADING TO CHANGES OF MUCOSA LEADING TO NEOPLASTIC TRANSFORMATION.NEOPLASTIC TRANSFORMATION.

SUCH CHANGES M/b REVERSIBLE IF SUCH CHANGES M/b REVERSIBLE IF TOBACCO EXPOSURE IS ELIMINATED EARLY. TOBACCO EXPOSURE IS ELIMINATED EARLY.

SO IT IS A PREVENTABLE DISEASE SO IT IS A PREVENTABLE DISEASE

40% OF PATIENTS WHO PERSISTED 40% OF PATIENTS WHO PERSISTED SMOKING AFTER PRESUMABLE CURE SMOKING AFTER PRESUMABLE CURE OF ORAL CANCER DEVELOPED OF ORAL CANCER DEVELOPED SECOND CANCER COMPARED TO 6% SECOND CANCER COMPARED TO 6% OF THOSE WHO STOPPED SMOKING OF THOSE WHO STOPPED SMOKING

TOBACCO CONTAINS CARCINOGENS TOBACCO CONTAINS CARCINOGENS THAT ACT DIRECTLY ON MUCOSATHAT ACT DIRECTLY ON MUCOSA

INCIDENCE IN WOMEN IS INCREASING INCIDENCE IN WOMEN IS INCREASING BECAUSE OF INCREASING HABIT OF BECAUSE OF INCREASING HABIT OF SMOKING & DRINKING.SMOKING & DRINKING.

ALCOHOLALCOHOL 75-80% OF PATIENTS WITH CANCER 75-80% OF PATIENTS WITH CANCER

CONSUME ALCOHOL.CONSUME ALCOHOL. 6 TIMES > IN DRINKER THAN NON 6 TIMES > IN DRINKER THAN NON

DRINKERDRINKER ALCOHOL ACT AS DIRECT IRRITANT & ALCOHOL ACT AS DIRECT IRRITANT &

ADD NUTRITIONAL DEFICIENCY.ADD NUTRITIONAL DEFICIENCY. STUDY SHOWS THAT DYSPLASTIC STUDY SHOWS THAT DYSPLASTIC

CHANGES IN THE MUCOSA OF NON CHANGES IN THE MUCOSA OF NON SMOKING ALCOHOLIC PATIENTS, SMOKING ALCOHOLIC PATIENTS, SUGGESTING THAT ALCOHOL ITSELF SUGGESTING THAT ALCOHOL ITSELF IS A CARCINOGEN.IS A CARCINOGEN.

PERSONS USES BOTH ALCOHOL & PERSONS USES BOTH ALCOHOL & TOBACCO ARE AT HIGHER RISK THAN TOBACCO ARE AT HIGHER RISK THAN THOSE USE ONE. THOSE USE ONE.

POOR ORAL & DENTAL POOR ORAL & DENTAL HYGIENE.HYGIENE.

CHRONIC IRRITATION FROM CHRONIC IRRITATION FROM SHARP TOOTH, ORAL SEPSIS, SHARP TOOTH, ORAL SEPSIS, SPICESSPICES

SYPHILISSYPHILIS PLUMMER-VINSON PLUMMER-VINSON

SYNDROME.SYNDROME.

VIT. A DEFICIENCYVIT. A DEFICIENCY ATAXA TELANGIECTASIA, ATAXA TELANGIECTASIA,

FANCONI ANEMIAFANCONI ANEMIA MARIJUANA = INCREASING MARIJUANA = INCREASING

INCIDENCE TO TONGUE CANCER INCIDENCE TO TONGUE CANCER IN YOUNG MALE.IN YOUNG MALE.

VIRUS = HSV-I & HPV 2, 11, 16VIRUS = HSV-I & HPV 2, 11, 16 FRESH FRUITS & VEGETABLES FRESH FRUITS & VEGETABLES

ARE PROTECTIVE. ARE PROTECTIVE.

PATHOLOGYPATHOLOGY 95% OF TONGUE CANCER ARE SCC95% OF TONGUE CANCER ARE SCC RATIO OF SCC ANT 2/3 TO POST 1/3 RATIO OF SCC ANT 2/3 TO POST 1/3

= 4:1= 4:1 OTHERS – MELANOMA, SARCOMA, OTHERS – MELANOMA, SARCOMA,

MINOR SALIVARY GLAND CANCER MINOR SALIVARY GLAND CANCER ADENOCYSTIC CARCINOMA, ADENOCYSTIC CARCINOMA, ADENOCARCINOMAADENOCARCINOMA

METASTATIC CA TONGUE IS RAREMETASTATIC CA TONGUE IS RARE

PREMALIGNANT CONDITIONPREMALIGNANT CONDITION

DEFINIT RISK OF MALIGNANT CHANGES:-DEFINIT RISK OF MALIGNANT CHANGES:-

1.1. LEUCOPLAKIALEUCOPLAKIA

2.2. ERYTHROPLAKIAERYTHROPLAKIA

3.3. CHRONIC HYPERPLASTIC CANDISIASISCHRONIC HYPERPLASTIC CANDISIASIS

LEUCOPLAKIALEUCOPLAKIA

WHITE PLAQUE ON MUCOSA THAT CAN WHITE PLAQUE ON MUCOSA THAT CAN NOT BE REMOVED BY SCRAPING AND CAN NOT BE REMOVED BY SCRAPING AND CAN NOT BE CLASSIFIED CLINICALLY OR NOT BE CLASSIFIED CLINICALLY OR PATHOLOGICALLY AS ANY OTHER PATHOLOGICALLY AS ANY OTHER DISEASE.DISEASE.

SMALL CIRCUMSCRIBED WHITE PLAQUESMALL CIRCUMSCRIBED WHITE PLAQUE SMOOTH, WRINKLED WITH FISSURES SMOOTH, WRINKLED WITH FISSURES WHITE TO YELLOWISH OR GREY WHITE TO YELLOWISH OR GREY HOMOGENOUS OR NODULAR SPECKLEDHOMOGENOUS OR NODULAR SPECKLED NODULAR & SPECKLED ARE MOST LIKELY NODULAR & SPECKLED ARE MOST LIKELY

TO UNDERGO MALIGNANT CHANGES TO UNDERGO MALIGNANT CHANGES

INCIDENCE OF MALIGNANT CHANGES INCIDENCE OF MALIGNANT CHANGES

INCREASES INCREASES WITHWITH THE AGE OF THE AGE OF LEUCOPLAKIALEUCOPLAKIA

2.4% MALIGNANT TRANSFORMATION RATE 2.4% MALIGNANT TRANSFORMATION RATE AT 10 YR.AT 10 YR.

4% MALIGNANT TRANSFORMATION RATE 4% MALIGNANT TRANSFORMATION RATE AT 20 YR.AT 20 YR.

MALIGNANT TRANSFORMATION RISK MALIGNANT TRANSFORMATION RISK INCREASES WITH THE AGE OF PATIENTSINCREASES WITH THE AGE OF PATIENTS

< 50 YR. < 50 YR. – 1%– 1% 70 - 89 YR. 70 - 89 YR. – 7.5%– 7.5%

DURING 5 YEARS OBSERVATION

LEUCOPLAKIA OF FLOOR OF LEUCOPLAKIA OF FLOOR OF MOUTH & VENTRAL SURFACE OF MOUTH & VENTRAL SURFACE OF TONGUE HAS HIGH INCIDENCE OF TONGUE HAS HIGH INCIDENCE OF MALIGNANCYMALIGNANCY

INDURATIONS S/o MALIGNANT INDURATIONS S/o MALIGNANT CHANGES, INDICATION FOR CHANGES, INDICATION FOR BIOPSYBIOPSY

TRETMENT WITH SURGICAL TRETMENT WITH SURGICAL EXCESION OR CO2 LASEREXCESION OR CO2 LASER

ERYTHROPLAKIAERYTHROPLAKIA

ANY LESION OF ORAL MUCOSA THAT ANY LESION OF ORAL MUCOSA THAT PRESENT AS BRIGHT RED VELVETY PRESENT AS BRIGHT RED VELVETY PLAQUE THAT CAN NOT BE PLAQUE THAT CAN NOT BE CHARACTERIZED CLINICALLY OR CHARACTERIZED CLINICALLY OR PATHOLOGICALLY ANY OTHER DISEASEPATHOLOGICALLY ANY OTHER DISEASE

IRREGULAR & CLEARLY DEMARCATED IRREGULAR & CLEARLY DEMARCATED FROM NORMAL EPITHELIUMFROM NORMAL EPITHELIUM

INCIDENCE OF MALIGNANT CHANGES IS INCIDENCE OF MALIGNANT CHANGES IS 17 TIME HIGHER THAN LEUCOPLAKIA17 TIME HIGHER THAN LEUCOPLAKIA

MUST BE EXCISED SURGICALLY. MUST BE EXCISED SURGICALLY.

OTHERS LESIONSOTHERS LESIONS

ORAL SUBMUCOUS FIBROSIS ORAL SUBMUCOUS FIBROSIS

SYPHILITIC GLOSSITISSYPHILITIC GLOSSITISSIDEROPENIC DYSPHASIASIDEROPENIC DYSPHASIAORAL LICHEN PLANUSORAL LICHEN PLANUS

PATHOLOGICAL VARIETIESPATHOLOGICAL VARIETIES1.1. ULCERATIVEULCERATIVE2.2. WARTY GROWTHWARTY GROWTH3.3. INDURATED PLAQUE OR MASSINDURATED PLAQUE OR MASS4.4. FISSUREFISSURE ULCERATIVE VARIETY COMMONESTULCERATIVE VARIETY COMMONEST IRREGULAR WITH EVERTED EDGES & IRREGULAR WITH EVERTED EDGES &

INDURATED BASEINDURATED BASE WARTY GROWTH IS USUALLY WARTY GROWTH IS USUALLY

SUPERIMPOSED ON PREVIOUS SUPERIMPOSED ON PREVIOUS LEUCOPLAKIALEUCOPLAKIA

FISSURE IS CHRONIC & FOLLOWS FISSURE IS CHRONIC & FOLLOWS CHRONIC SUPERFECIAL GLOSSITITS OR CHRONIC SUPERFECIAL GLOSSITITS OR SYPHILISSYPHILIS

MODE OF SPREADMODE OF SPREADLOCAL SPREAD LOCAL SPREAD BY INFILTRATION & INVASIONBY INFILTRATION & INVASION ANT 2/3 OF TONGUE – FLOOR OF MOUTH, ANT 2/3 OF TONGUE – FLOOR OF MOUTH,

CROSS THE MIDLINE CROSS THE MIDLINE MANDIBLE INFILTRATION OCCUR THROUGH MANDIBLE INFILTRATION OCCUR THROUGH

ITS DENTAL SOCKET OR EDENTULOUS ITS DENTAL SOCKET OR EDENTULOUS ALVEOLAR RIDGE, CELLS PROCEED ALONG ALVEOLAR RIDGE, CELLS PROCEED ALONG THE ROOT OF TOOTH INTO THE CANCELLOUS THE ROOT OF TOOTH INTO THE CANCELLOUS PART OF MANDIBLE & THAN ALONG THE PART OF MANDIBLE & THAN ALONG THE MANDIBULAR CANAL.MANDIBULAR CANAL.

POST 1/3 OF TONGUE – TONSIL, PHARYNX, POST 1/3 OF TONGUE – TONSIL, PHARYNX, PALATE, EPIGLOTTIS.PALATE, EPIGLOTTIS.

LYMPHATIC SPREAD:LYMPHATIC SPREAD:

FREQUENTLY METASTASIZES B/LFREQUENTLY METASTASIZES B/L

POST 1/3 EMBOLIC SPREAD NOT BY POST 1/3 EMBOLIC SPREAD NOT BY

PERMEATION PERMEATION

B/L SPREAD - 25%B/L SPREAD - 25%

CONTRALATRAL SPREAD - 3% CONTRALATRAL SPREAD - 3%

BLOOD SPREAD IS BLOOD SPREAD IS

RARE MOSTLY WITH POST 1/3RARE MOSTLY WITH POST 1/3

CLINICAL FEATURESCLINICAL FEATURES COMMEST PRESENTATION IS PAINLESS COMMEST PRESENTATION IS PAINLESS

LUMP OR ULCER ON THE SURFACE OF LUMP OR ULCER ON THE SURFACE OF TONGUE.TONGUE.

EXCESSIVE SALIVATION – ELDERLY MAN EXCESSIVE SALIVATION – ELDERLY MAN SITTING IN OPD WITH FREQUENT SITTING IN OPD WITH FREQUENT SPITTING IN TO HANDKERCHIEF .SPITTING IN TO HANDKERCHIEF .

PAIN – LATE FEATUREPAIN – LATE FEATURE– DUE TO INVOLVEMENT OF NERVESDUE TO INVOLVEMENT OF NERVES

– LOCALISED OR REFERRED TO EARLOCALISED OR REFERRED TO EAR

– ON SWALLOWING – IN POST 1/3 TONGUE CA ON SWALLOWING – IN POST 1/3 TONGUE CA

DIFFICULTY IN SPEECH – POST 1/3 DIFFICULTY IN SPEECH – POST 1/3 TONGUE CANCERTONGUE CANCER

INFILTRATION OF MUSCLES & FLOOR INFILTRATION OF MUSCLES & FLOOR OF MOUTH – ANKYLO GLOSSIAOF MOUTH – ANKYLO GLOSSIA

FETOR ORIS, BLEEDING PRESENT FETOR ORIS, BLEEDING PRESENT DUE TO TUMOR NECROSIS & DUE TO TUMOR NECROSIS & INFECTION.INFECTION.

TRISMUS - INVOLVEMENT OF TRISMUS - INVOLVEMENT OF PTERYGOID MUSCLEPTERYGOID MUSCLE

MANDIBULAR ANESTHESIA – BONE MANDIBULAR ANESTHESIA – BONE EROSION WITH INVOLMENT OF EROSION WITH INVOLMENT OF ALVEOLAR NERVE. ALVEOLAR NERVE.

DIAGNOSTIC STUDYDIAGNOSTIC STUDY CLINICAL EXAMINATION WITH HIGH INDEX OF CLINICAL EXAMINATION WITH HIGH INDEX OF

CLINICAL SUSPICION.CLINICAL SUSPICION. BIOPSY- INCISIONAL BIOPSY OF MOST BIOPSY- INCISIONAL BIOPSY OF MOST

SUSPICIOUS PART WITH NORMAL ADJOINING SUSPICIOUS PART WITH NORMAL ADJOINING MUCOSA IS MANDATORY BEFORE PLANNING MUCOSA IS MANDATORY BEFORE PLANNING TREATMENT. BIOPSY CAN BE TAKEN UNDER TREATMENT. BIOPSY CAN BE TAKEN UNDER LA.LA.

FNAC – FROM NECK NODES.FNAC – FROM NECK NODES. ORTHOPANTOMOGRAM (OPG) OR OBLIQUE ORTHOPANTOMOGRAM (OPG) OR OBLIQUE

VIEW RADIOGRAPH OF MANDIBLE IS VIEW RADIOGRAPH OF MANDIBLE IS EFFECTIVE INITIAL INVESTIGATION TO EFFECTIVE INITIAL INVESTIGATION TO ASSESS MANDIBULAR INVASION. ASSESS MANDIBULAR INVASION.

CT SCANCT SCAN - FOR CERVICAL METASTASIS - FOR CERVICAL METASTASIS INFILTRATION OF MANDIBLE.INFILTRATION OF MANDIBLE.

MRI – MRI – INVESTIGATION OF CHOICE FOR INVESTIGATION OF CHOICE FOR IMAGING SOFT TISSUE INFILTRATION. CAN IMAGING SOFT TISSUE INFILTRATION. CAN DETECT PERINEURAL INVASION. DETECT PERINEURAL INVASION.

X-RAY – X-RAY – LIMITED VALUE D/T COMPLEXITY LIMITED VALUE D/T COMPLEXITY OF FASICAL BONE. MAY SHOW OF FASICAL BONE. MAY SHOW PULMONARY METASTASIS.PULMONARY METASTASIS.

ROUTINE INVESTIGATION WITH VDRL/ ROUTINE INVESTIGATION WITH VDRL/ KHANS TEST ETC.KHANS TEST ETC.

DIRECT LARYNGOSCOPY – FOR BASE OF DIRECT LARYNGOSCOPY – FOR BASE OF TONGUE CA & TO KNOW THE FIELD TONGUE CA & TO KNOW THE FIELD CANCERIZATION (SYNCHRONOS AND CANCERIZATION (SYNCHRONOS AND METACHRONOUS SECOND MALIGNANCIES)METACHRONOUS SECOND MALIGNANCIES)

STAGING OF TONGUE CANCERSTAGING OF TONGUE CANCER

PRIMARY TUMOR (T)PRIMARY TUMOR (T)

TxTx -- TUMOR CAN NOT BE ASSESSEDTUMOR CAN NOT BE ASSESSED

T0T0 -- NO EVIDENCE OF PNO EVIDENCE OF P00 TUMOR TUMOR

TisTis -- CARCINOMA IN SITUCARCINOMA IN SITU

T1T1 -- GREATEST DIAMETER = GREATEST DIAMETER = ≤ 2 cm.≤ 2 cm.

T2T2 -- > 2 cm. TO 4 cm.> 2 cm. TO 4 cm.

T3T3 -- > 4 cm.> 4 cm.

T4T4 -- ORAL TONGUEORAL TONGUE

T4aT4a -- INVASION OF CORTICAL BONE, INVASION OF CORTICAL BONE,

DEEP EXTRINSIC MUSCLE, DEEP EXTRINSIC MUSCLE,

MAXILLARY SINUS, SKIN OF MAXILLARY SINUS, SKIN OF

FACE.FACE.

T4b T4b -- PTERYGOID PLATE SKULL PTERYGOID PLATE SKULL

BASE, INVOLVEMENT OF ICABASE, INVOLVEMENT OF ICA

T4T4 -- BASE OF TONGUEBASE OF TONGUE

T4aT4a -- LARYNX, MEDIAL PTERYGOID, LARYNX, MEDIAL PTERYGOID,

HARD PALATE, MANDIBLE HARD PALATE, MANDIBLE

T4b T4b -- LATERAL PTERYGOID, LATERAL PTERYGOID,

NASOPHARYNX , ICA,.NASOPHARYNX , ICA,.

LYMPH NODELYMPH NODE Nx – REGIONAL LN CAN NOT BE ASSESSEDNx – REGIONAL LN CAN NOT BE ASSESSED N0 – NO NODAL METASTASISN0 – NO NODAL METASTASIS N1 – IPSILATERAL SINGLE LN N1 – IPSILATERAL SINGLE LN ≤≤ 3cm. 3cm. N2 :N2 :

– N2A – IPSILATERAL SINGLE LN > 3cm. - 6 cm. N2A – IPSILATERAL SINGLE LN > 3cm. - 6 cm. – N2B – IPSILATERAL MULTIPLE LN N2B – IPSILATERAL MULTIPLE LN ≤ 6 cm.≤ 6 cm.

– N2C – BILATERAL / CONTRALATERAL LN N2C – BILATERAL / CONTRALATERAL LN ≤ 6 cm.≤ 6 cm. N3 – ANY NODE > 6 cm.N3 – ANY NODE > 6 cm. MIDLINE NODES ARE CONSIDERED AS MIDLINE NODES ARE CONSIDERED AS

IPSILATERALIPSILATERAL

DISTANT METASTASISDISTANT METASTASIS Mx Mx – – CAN NOT BE CAN NOT BE

ASSESSEDASSESSED M0 M0 – – NO DETECTABLE NO DETECTABLE

DISTANT DISTANT METASTASISMETASTASIS

M1 M1 – – DISTANT DISTANT METASTASIS METASTASIS PRESENTPRESENT

CLINICAL STAGING GROUPING CLINICAL STAGING GROUPING STAGE T N M

I T1 N0 M0

II T2 N0 M0

III T1 N1 M0

T2 N1 M0

T3 NO/N1 M0

IV A T4 N0 M0

T4 N1 M0

ANY T N2 M0

IV B ANY T N3 M0

IV C ANY T ANY N M1

TREATMENTSTREATMENTS CHOICE OF TREATMENT DEPENDS CHOICE OF TREATMENT DEPENDS

UPON VARIOUS FACTORS UPON VARIOUS FACTORS SITE OF DISEASESITE OF DISEASE STAGE OF DISEASE:STAGE OF DISEASE:

– EARLY EARLY – SURGERY – SURGERY

– INTERMEDIATE – BOTH (Surgery & RT)INTERMEDIATE – BOTH (Surgery & RT)

– ADVANCEDADVANCED – BOTH (Surgery & RT) – BOTH (Surgery & RT)

PREVIOUS IRRADIATIONPREVIOUS IRRADIATION

PATIENTS PHYSICAL / SOCIAL & PATIENTS PHYSICAL / SOCIAL & PERSONAL STATUSPERSONAL STATUS

SURGEON'S EXPERIENCE & SKILLSURGEON'S EXPERIENCE & SKILL

AVAILABILITY OF TREATMENT AVAILABILITY OF TREATMENT FACILITIESFACILITIES

SURGICAL TREATMENTSSURGICAL TREATMENTSAIMs OF SURGERYAIMs OF SURGERY COMPLETE EXCISION OF PRIMARY, COMPLETE EXCISION OF PRIMARY,

THREE DIMENSIONALLY WITH Ro THREE DIMENSIONALLY WITH Ro (MICROSCOPICALLY CLEAR) MARGINS.(MICROSCOPICALLY CLEAR) MARGINS.

Rx OF LNRx OF LN RECONSTRUCTION OF TISSUE LOSS TO RECONSTRUCTION OF TISSUE LOSS TO

PROVIDE RAPID HEALING, PROVIDE RAPID HEALING, RESTORATION OF FUNCTION & RESTORATION OF FUNCTION & APPEARANCE TO IMPROVE QUALITY OF APPEARANCE TO IMPROVE QUALITY OF LIFE.LIFE.

LOCAL EXCISIONLOCAL EXCISION PER ORAL RESECTION IN SMALL PER ORAL RESECTION IN SMALL

LESION (≤ 2cm.) LOCATED AT TIP, LESION (≤ 2cm.) LOCATED AT TIP, LATERAL BORDER ANT 2/3 OF LATERAL BORDER ANT 2/3 OF TONGUE THAT ARE TONGUE THAT ARE APPROACHABLE 2 cm. MARGIN APPROACHABLE 2 cm. MARGIN

LOCALISED PREMALIGNANT LOCALISED PREMALIGNANT LESION ARE ALSO TREATED BY LESION ARE ALSO TREATED BY THIS METHOD. THIS METHOD.

LASER EXCESION – MINIMAL LASER EXCESION – MINIMAL BLEED, SCAR&RAPID HEALING BLEED, SCAR&RAPID HEALING

PARTIAL GLOSSECTOMY WITH PARTIAL GLOSSECTOMY WITH SPARING OF MANDIBLESPARING OF MANDIBLE

APPLICABLE FOR SMALL SUPERFICIAL WELL APPLICABLE FOR SMALL SUPERFICIAL WELL DIFFERENTIATED LESION OF ORAL TONGUE DIFFERENTIATED LESION OF ORAL TONGUE WHICH ARE TWO LARGE FOR LOCAL EXCISION & WHICH ARE TWO LARGE FOR LOCAL EXCISION & TUMOR NOT INVOLVING THE MANDIBLE.TUMOR NOT INVOLVING THE MANDIBLE.

USUALLY DONE ALONG WITH BLOCK DISSECTION USUALLY DONE ALONG WITH BLOCK DISSECTION OF NECK OF NECK

INCISION: MASTOID TIP TO MID LINE CHIN TWO INCISION: MASTOID TIP TO MID LINE CHIN TWO FINGER BELOW THE LOWER BORDER OF FINGER BELOW THE LOWER BORDER OF MANDIBLEMANDIBLE

RIGHT ANGLE TO UPPER INCISION & POST TO RIGHT ANGLE TO UPPER INCISION & POST TO CAROTID ARTERY & DOWNWORD UP TO THE CAROTID ARTERY & DOWNWORD UP TO THE CLAVICLE CLAVICLE

BLOCK DISSECTION IS BLOCK DISSECTION IS COMPLETED TO THE LEVEL OF COMPLETED TO THE LEVEL OF HYOID & CAROTID BIFURCATIONHYOID & CAROTID BIFURCATION

LINGUAL ARTERY IS LEGATED LINGUAL ARTERY IS LEGATED NEAR THE HYOID NEAR THE HYOID

IPSILATERAL SUBMANDIBULAR IPSILATERAL SUBMANDIBULAR GLAND IS SEPARATED FROM GLAND IS SEPARATED FROM INFERIOR SURFACE OF MANDIBLEINFERIOR SURFACE OF MANDIBLE

FACIAL VESSELS ARE LIGATEDFACIAL VESSELS ARE LIGATED LIP IS SPLIT IN MIDLINE. LIP IS SPLIT IN MIDLINE.

PERIOSTEUM IS ELEVATED FROM PERIOSTEUM IS ELEVATED FROM EXT. SURFACE OF MANDIBLE FOR EXT. SURFACE OF MANDIBLE FOR 2 cm. IN BOTH THE DIRECTION2 cm. IN BOTH THE DIRECTION

INNER PERIOSTEUM ELEVATED INNER PERIOSTEUM ELEVATED FROM SYMPHISIS TO ANGLE FROM SYMPHISIS TO ANGLE

TOOTH , LATERAL INCISOR IS TOOTH , LATERAL INCISOR IS EXTRACTED EXTRACTED

MANDIBLE IS DIVIDED JUST OFF MANDIBLE IS DIVIDED JUST OFF THE MIDLINE WITH GIGLI SAW.THE MIDLINE WITH GIGLI SAW.

MUCOSAL INCISION IS MADE IN MUCOSAL INCISION IS MADE IN GINGIVO LINGUAL SULCUS GINGIVO LINGUAL SULCUS FROM THE POINT OF FROM THE POINT OF MANDIBULAR DIVISION TO THE MANDIBULAR DIVISION TO THE ANT PILLARANT PILLAR

LEAVING 5MM OF FREE MUCOSA LEAVING 5MM OF FREE MUCOSA ATTACHED TO MANDIBLEATTACHED TO MANDIBLE

MANDIBLE IS RETRACTED LATERALLYMANDIBLE IS RETRACTED LATERALLY TRACTION SUTURES ARE APPLIED IN TRACTION SUTURES ARE APPLIED IN

THE TIP OF TONGUETHE TIP OF TONGUE GLOSSECTOMY IS PERFORMED WITH GLOSSECTOMY IS PERFORMED WITH

DIATHERMY TO MAXIMIZE HEMOSTASIS DIATHERMY TO MAXIMIZE HEMOSTASIS & 2 CM MARGIN OF NORMAL TONGUE IS & 2 CM MARGIN OF NORMAL TONGUE IS MAINTAIND IN ALL DIRECTION. MAINTAIND IN ALL DIRECTION.

CAUTRY INCISION IS MADE IN MIDLINE CAUTRY INCISION IS MADE IN MIDLINE OF TONGUE FROM ANT TO POST. OF TONGUE FROM ANT TO POST.

ANT FROM TIP TO FLOOR &FROM ANT FROM TIP TO FLOOR &FROM POST TURNING TO LATERALLY UP TO POST TURNING TO LATERALLY UP TO THE ANT PILLAR.THE ANT PILLAR.

WHOLE TISSUE IS TAKEN WITH WHOLE TISSUE IS TAKEN WITH BLOCK DISSECTION SPECIMEN. BLOCK DISSECTION SPECIMEN. MANDIBULAR FRAGMENTS ARE MANDIBULAR FRAGMENTS ARE REALIGNED &STABILISED WITH REALIGNED &STABILISED WITH STEEL WIRE OR TITANEUM PLATESTEEL WIRE OR TITANEUM PLATE

TONGUE DEFECT CAN BE COVERED TONGUE DEFECT CAN BE COVERED WITH FREE SKIN GRAFT OR PMMC WITH FREE SKIN GRAFT OR PMMC FLAPFLAP

WOUND IS CLOSED UNDER VACUUM WOUND IS CLOSED UNDER VACUUM SUCTION.SUCTION.

MARGINAN MANDIBULECTOMYMARGINAN MANDIBULECTOMY INDICATED IN CANCER IN CLOSE INDICATED IN CANCER IN CLOSE

PROXIMITY TO LOWER GINGIVAL OR PROXIMITY TO LOWER GINGIVAL OR EXTENDING TO MANDIBLE WITHOUT EXTENDING TO MANDIBLE WITHOUT CLINICAL OR RADIOLOGICAL CLINICAL OR RADIOLOGICAL INVOLVEMENT OR WITH MINIMAL INVOLVEMENT OR WITH MINIMAL CORTICAL INVASION.CORTICAL INVASION.

INVOLVES THE INCONTINUITY EXCESION INVOLVES THE INCONTINUITY EXCESION OF TUMOR WITH MARGIN OF MANDIBLE OF TUMOR WITH MARGIN OF MANDIBLE AND OVERLYING GINGIVAL.AND OVERLYING GINGIVAL.

MADIBULAR CONTINUITY IS MAINTAINED MADIBULAR CONTINUITY IS MAINTAINED AND MUCH BETTER COSMETIC & AND MUCH BETTER COSMETIC & FUNCTIONAL END RESULT ACHIEVED.IF FUNCTIONAL END RESULT ACHIEVED.IF MANDIBLE IS DIRECTLY INVOLVED THAN MANDIBLE IS DIRECTLY INVOLVED THAN SEGMENTAL MANDIBULECTOMY IS DONE.SEGMENTAL MANDIBULECTOMY IS DONE.

TOTAL GLOSSECTOMYTOTAL GLOSSECTOMY INDICATED FOR MASSIVE LOCAL INDICATED FOR MASSIVE LOCAL

CARCINOMA OF TONGUE CARCINOMA OF TONGUE LIP IS SPLIT IN MIDLINELIP IS SPLIT IN MIDLINE B/L CHEEK FLAP ARE RAISED BEYOND B/L CHEEK FLAP ARE RAISED BEYOND

THE ANGLE OF MANDIBLETHE ANGLE OF MANDIBLE MUCOSA IS INCISED IN BOTH GINGIVO-MUCOSA IS INCISED IN BOTH GINGIVO-

BUCCAL SULCUS BACK TO THE ANT BUCCAL SULCUS BACK TO THE ANT PILLARPILLAR

ASENDING RAMI OF MANDIBLE IS ASENDING RAMI OF MANDIBLE IS DIVIDED DIVIDED

WHOLE SPECIMEN IS TAKEN OUTWHOLE SPECIMEN IS TAKEN OUT

K –WIRE CAN BE INSERTED FOR K –WIRE CAN BE INSERTED FOR MANDIBLEMANDIBLE

DEFECT OF TOTAL GLOSSECTOMY DEFECT OF TOTAL GLOSSECTOMY CONSISTS OF TONGUE, FLOOR OF CONSISTS OF TONGUE, FLOOR OF MOUTH & SOME TISSUE PHARYNGEAL MOUTH & SOME TISSUE PHARYNGEAL & LARYNGEAL MUCOSA.& LARYNGEAL MUCOSA.

PECTORALIS MAJOR FLAP OR PECTORALIS MAJOR FLAP OR TEMPARAL FLAP CAN GIVE GOOD TEMPARAL FLAP CAN GIVE GOOD RESULT.RESULT.

CARCINOMA OF BASE OF TONGUE CARCINOMA OF BASE OF TONGUE ARE USUALLY ADVANCE & METASTIC ARE USUALLY ADVANCE & METASTIC AT THE TIME OF PRESENTATIONAT THE TIME OF PRESENTATION

TREATMENT OF POST 1/3 OF TONGUE TREATMENT OF POST 1/3 OF TONGUE IS USUALLY TELE THERAPY SINCE IS USUALLY TELE THERAPY SINCE THE SITE IS ANATOMICALLY THE SITE IS ANATOMICALLY DIFFICULT FOR BOTH SURGERY AND DIFFICULT FOR BOTH SURGERY AND FOR INTERSTITIAL IRRADIATION.FOR INTERSTITIAL IRRADIATION.

MEDIAN TRANSLINGUIAL PHARYNGOTOMYMEDIAN TRANSLINGUIAL PHARYNGOTOMY MID LINE OF TONGUE IS INCISED, MID LINE OF TONGUE IS INCISED,

BISECTING THE TONGUE IN TWO b/l BISECTING THE TONGUE IN TWO b/l SEGMENTSEGMENT

INCISION EXTEND BACK TO THE AREA INCISION EXTEND BACK TO THE AREA OF TUMOR IN THE BASE OF TONGUE.OF TUMOR IN THE BASE OF TONGUE.

TUMOR IS EXCISED & WOUND TUMOR IS EXCISED & WOUND CAN BE CLOSED PRIMARILY.CAN BE CLOSED PRIMARILY.

MID LINE OF TONGUE IS MID LINE OF TONGUE IS INCISED, BISECTING THE INCISED, BISECTING THE TONGUE IN TWO b/l SEGMENTTONGUE IN TWO b/l SEGMENT

INCISION EXTEND BACK TO THE INCISION EXTEND BACK TO THE AREA OF TUMOR IN THE BASE AREA OF TUMOR IN THE BASE OF TONGUE.OF TONGUE.

TUMOR IS EXCISED & WOUND TUMOR IS EXCISED & WOUND CAN BE CLOSED PRIMARILY.CAN BE CLOSED PRIMARILY.

TRANS HYOID PHARYNGOTOMYTRANS HYOID PHARYNGOTOMY COLLAR INCISION IS MADE AT COLLAR INCISION IS MADE AT

HYOID LEVEL b/w THE SCM HYOID LEVEL b/w THE SCM MUSCLES.MUSCLES.

SKIN FLAPS ELEVATEDSKIN FLAPS ELEVATED SUPAR & INFRA HYOID SUPAR & INFRA HYOID

MUSCLES ARE EXCISED MUSCLES ARE EXCISED CENTRAL PORTION OF HYOID CENTRAL PORTION OF HYOID

IS EXCISED.IS EXCISED.

TUMOR AT BASE IS EXCISED WITH TUMOR AT BASE IS EXCISED WITH 2 cm. MARGIN.2 cm. MARGIN.

AVOID INJURY TO LINGUAL AVOID INJURY TO LINGUAL ARTERY & HYPOGLOSSAL NERVE.ARTERY & HYPOGLOSSAL NERVE.

DEFECT IS CLOSED PRIMARILY.DEFECT IS CLOSED PRIMARILY. IF TUMOR HAS INVOLVED THE IF TUMOR HAS INVOLVED THE

EPIGLOTTIS & PART OF GLOTTIS. EPIGLOTTIS & PART OF GLOTTIS. THEN SUPRAGLOTTIC THEN SUPRAGLOTTIC LARYGECTOMY CAN BE DONE. LARYGECTOMY CAN BE DONE.

ADVANCE STAGE CARCINOMA OF ADVANCE STAGE CARCINOMA OF TONGUE REQUIRED COMBINED TONGUE REQUIRED COMBINED MODALITY OF RADICAL SURGERY MODALITY OF RADICAL SURGERY WITH RECONSTRUCTION WITH RECONSTRUCTION FOLLOWED BY POST OPERATIVE RTFOLLOWED BY POST OPERATIVE RT

COMMANDO OPERATION CONSISTS COMMANDO OPERATION CONSISTS OF COMPOSITE RESECTION OF OF COMPOSITE RESECTION OF PRIMARY MALIGNANCY, PRIMARY MALIGNANCY, HEMIMANDIBULECTOMY WITH HEMIMANDIBULECTOMY WITH IPSILATERAL OR BILATERAL RND.IPSILATERAL OR BILATERAL RND.

USEFUL IN FAR ADVANCED USEFUL IN FAR ADVANCED CARCINOMA. CARCINOMA.

DELEOPECTORAL SKIN FLAPDELEOPECTORAL SKIN FLAP

MANDIBULAR TONGUE PROSTHESISMANDIBULAR TONGUE PROSTHESIS

RADIO THERAPYRADIO THERAPYRT & SURGERY HAVE EQUAL SUCCESS RT & SURGERY HAVE EQUAL SUCCESS IN EARLY LESION. RT CAN BE GIVEN:IN EARLY LESION. RT CAN BE GIVEN:

BRACHYTHERPYBRACHYTHERPY TELE THERAPY – EBRTTELE THERAPY – EBRT COMBINATION THERAPYCOMBINATION THERAPY RT MAY HELP IN ORGAN PRESERVTION RT MAY HELP IN ORGAN PRESERVTION

BUT LONG TERM COMPLICATION ARE BUT LONG TERM COMPLICATION ARE SIGNIFICANTSIGNIFICANT

XEROSTOMIA, ERYTHEMA, SKIN XEROSTOMIA, ERYTHEMA, SKIN SLOUGHING, ULCERATION, DENTAL SLOUGHING, ULCERATION, DENTAL CARIES & OSTEORADIONECROSIS. CARIES & OSTEORADIONECROSIS.

POST OPERATIVE RT IS PREFERRED OVER POST OPERATIVE RT IS PREFERRED OVER PRE OPERATIVE B/C OF EFFECT ON PRE OPERATIVE B/C OF EFFECT ON WOUND HEALING WOUND HEALING

PER OPERATIVE RT: INOPERABLE, UNFIT PER OPERATIVE RT: INOPERABLE, UNFIT FOR SURGERY& DOWN STAGINGFOR SURGERY& DOWN STAGING

POST RT IS INDICATED IN PATIENTS WITHPOST RT IS INDICATED IN PATIENTS WITH– TT33/T/T4 4 PRIMARY PRIMARY – POSITIVE SURGICAL MARGINESPOSITIVE SURGICAL MARGINES– PERINEURAL, PERILYMPHATIC PERINEURAL, PERILYMPHATIC

VASCULAR INVASIONVASCULAR INVASION– MIOROSCOPIC GROSS RESIDUAL TUMORMIOROSCOPIC GROSS RESIDUAL TUMOR– EXTRA CAPSULAR SPREADEXTRA CAPSULAR SPREAD– PATHOLOGICALLY POSITIVE LN AFTER PATHOLOGICALLY POSITIVE LN AFTER

SOHNDSOHND

EBRT DOSE – 6500 TO 7000 RAD TO EBRT DOSE – 6500 TO 7000 RAD TO PRIMARY & NECK FOR CLINICALLY PRIMARY & NECK FOR CLINICALLY EVIDENT DISEASE.EVIDENT DISEASE.

WIDE MARGIN OF TONGUE CAN BE WIDE MARGIN OF TONGUE CAN BE TREATEDTREATED

GIVEN AS 200 RAD PER DAY OVER 5 TO GIVEN AS 200 RAD PER DAY OVER 5 TO 7 WEEKS. 7 WEEKS.

BRACHYTHERAPHY CAN DELIVER BRACHYTHERAPHY CAN DELIVER LARGER DOSE TO THE GIVEN TISSUE.LARGER DOSE TO THE GIVEN TISSUE.

IRIDIUM 192,CAESIUM137, NEEDLES IRIDIUM 192,CAESIUM137, NEEDLES ARE USED. ARE USED.

IT REQUIRE ACCURATE SPACING OF IT REQUIRE ACCURATE SPACING OF INTERSTITIAL SEEDS OR NEEDLES TO INTERSTITIAL SEEDS OR NEEDLES TO PREVENT OVERLAPPING OF PREVENT OVERLAPPING OF RADIATION.RADIATION.

PRECISE DOSIMETRY ACHIEVED BY PRECISE DOSIMETRY ACHIEVED BY AFTER LOADING TECHNIQUE.AFTER LOADING TECHNIQUE.

RADIOACTIV SOURCE IS INSERTED IN TO RADIOACTIV SOURCE IS INSERTED IN TO PREVIOUSLY IMPLANTED HOLLOW PREVIOUSLY IMPLANTED HOLLOW NYLON TUBES.NYLON TUBES.

TUBES ARE PLACED UNDER GA TUBES ARE PLACED UNDER GA AS MUCH AS 10000 RAD CAN BE AS MUCH AS 10000 RAD CAN BE

DELIVERD TO SMALL AREA WITH DELIVERD TO SMALL AREA WITH GREATER EFFECT.GREATER EFFECT.

PROPHYLACTIC RADIATION IS DONE B/C PROPHYLACTIC RADIATION IS DONE B/C OE HIGH INCIDENCE OF OCCULT OE HIGH INCIDENCE OF OCCULT METASTASIS (40%). METASTASIS (40%).

CHEMOTHERAPYCHEMOTHERAPY USED IN PALLIATION IN ADVDNCED USED IN PALLIATION IN ADVDNCED

CA.CA. AGENTS ARE MTx,5-FU,CISPLATIN AGENTS ARE MTx,5-FU,CISPLATIN

BLEOMYCIN.BLEOMYCIN. COMBINED CT IS MORE EFFECTIVE COMBINED CT IS MORE EFFECTIVE

THAN SINGLE AGENT.THAN SINGLE AGENT. RESPONSE TO CISPLATIN+5FU RESPONSE TO CISPLATIN+5FU

OCCURE IN TWO THIRDS OF Pt WITH OCCURE IN TWO THIRDS OF Pt WITH COMPLETE RESPONSE IN 5-15% COMPLETE RESPONSE IN 5-15%

TREATMENT OF NECKTREATMENT OF NECK DEPEND ON NODAL STATUS.DEPEND ON NODAL STATUS. RND IS GOLD STANDARD.RND IS GOLD STANDARD. MRND GIVE BETTER COSMETIC & MRND GIVE BETTER COSMETIC &

FUNCTIONAL RESULT.FUNCTIONAL RESULT. CLASSIC RND : 5 LEVEL LN WITH SAN, CLASSIC RND : 5 LEVEL LN WITH SAN,

IJV, SCM.IJV, SCM. MRND : 5 LEVEL LN WITH MRND : 5 LEVEL LN WITH

PRESERVATION OF THE STRUCTURE.PRESERVATION OF THE STRUCTURE. TYPE-1 PRESERVE SAN.TYPE-1 PRESERVE SAN. TYPE-2 PRESERVES AN & IJV.TYPE-2 PRESERVES AN & IJV.

TYPE-3 PRESERVE SAN IJV &SCM.TYPE-3 PRESERVE SAN IJV &SCM. N-0 NECK S/B TREATED WITH N-0 NECK S/B TREATED WITH

SOHND.SOHND. PATHOLOGICALLY POSITIVE NODE PATHOLOGICALLY POSITIVE NODE

DETECTED ON TABLE BY FROZEN DETECTED ON TABLE BY FROZEN SECTION S/B TREATED BY SECTION S/B TREATED BY RND/MRND. RND/MRND.

IF DECTED AFTER HPE FOLLOWING IF DECTED AFTER HPE FOLLOWING SOHND Pt SHOULD UNDER GO RTSOHND Pt SHOULD UNDER GO RT

PROGNOSISPROGNOSIS

DEPENDS ON NODAL STATUS & DEPTH OF DEPENDS ON NODAL STATUS & DEPTH OF INVASION PERINEURAL & VASCUALR SPREAD INVASION PERINEURAL & VASCUALR SPREAD

STAGE 5 YEARS SURVIVAL

ORAL TONGUE BASE OF TONGUE

I 70% 60%

II 40% 40%

III 25% 30%

IV < 20% 15%

OVERALL SURVIVAL OF TOOUNGE CNANCER IS NEAR 50%.

RECURRENT DISEASERECURRENT DISEASE WHEN A PRIMARY RECUR AFTER RT OR WHEN A PRIMARY RECUR AFTER RT OR

SURGERY CRYOSURGERY OR LASER SURGERY CRYOSURGERY OR LASER VAPORIZATION CAN BE USED FOR VAPORIZATION CAN BE USED FOR PALLIATION.PALLIATION.

TERMINAL EVENTSTERMINAL EVENTS CANCER CACHEXIA & STARVATIONSCANCER CACHEXIA & STARVATIONS INHALATION BRONCHOPNEUMONIAINHALATION BRONCHOPNEUMONIA ASPHYXIA D/T OEDEMA OR PRESSURE ON ASPHYXIA D/T OEDEMA OR PRESSURE ON

AIR PASSAGE FROM A FIXED LNAIR PASSAGE FROM A FIXED LN EROSION OF ICA IN POST 1/3 CANCEREROSION OF ICA IN POST 1/3 CANCER EROSION OF LINGUAL ARTRY IN ART 2/3 EROSION OF LINGUAL ARTRY IN ART 2/3

CANCERCANCER