Carcinoma of Tongue and Oropharynx

Carcinoma of the tongue is constitutes about 3% of all cancer affecting the human population globally. Tobaccouse mainly in the form of cigarettes or smokeless form is one of the predominant factors affecting the patients with tongue cancer[1]. Prevalence of oral cancer is two to three times more in men than women all over the world.In the reports issued globally, cancers of all regions of the oral cavity and pharynx are grouped and collectively represent the sixth most common cancer in the world affecting the human population[2].Here we report a case of carcinoma of tongue affecting the posterior part of the tongue involving the oropharynx.

A 61 year old male patient reported to the department of oral medicine and radiology with a chief complain of a wound on the left side of the tongue since 1 month. Initially the wound appeared like a small nodule 1month ago which was slowly progressive and attained present size. Patient gave no history of difficulty in speech, swallowing and bleeding from the wound. Past medical history was non-contributory, Patient gave a history of extraction one month ago of the lower left back tooth. Brushes once daily consumes alcohol occasionally since thirty years. A solitary left submandibular lymph node was palpable measuring about one cm in diameter and non-tender. Intraoral examination revealed a solitary ulcero-proliferative growth on left lateral border of the tongue measuring 2.5 cm in diameter with rolled edges and yellowish slough over the surface.Areas of erythema seen on the borders. Extension of the ulceration is into the floor of the mouth and oropharyngeal region. Base of the ulcer was indurated and non-tender on palpation(Figure 1). A provisional diagnosis of carcinoma of the tongue was considered. Toluidine blue staining was performed and was positive. Incisional biopsy was performed and histopathological section revealed, epithelial cells with cellular and nuclear pleomorphism and altered nuclear cytoplasm mitotic figures sheets and islands invasion into salivary gland and skeletal muscles(Figure 2). A final diagnosis of moderately differentiated squamous cell carcinoma of the tongue was given. Surgical excision and followed by chemotherapy was advised and patient was recalled after a week. Patient was not keen of undergoing treatment, but after six months demise of the patient was informed by the concerned family relatives.

 

Figure 1: Ulcero proliferative lesion on the left lateral aspect of the tongue.

Figure 2: Histopathological section revealing epithelial cells with cellular and nuclear pleomorphism and altered nuclear cytoplasm mitotic figures sheets and islands invasion into salivary gland and skeletal muscles.

Carcinoma of the tongue is one of the most commonly occurring neoplasms among all oral tumors i.e. Thirtypercent of all the intraoral malignancies[3].Increase in use of tobacco can increase the chances of cancerous catastrophe. Other ethology is dental trauma due to presence of a sharp tooth edge, which could be traumatic with the predisposing factors which can cause oral cancer. A study reported that 44% of patients with carcinoma of tongue had a site of persistent mechanical irritation by sharp teeth or dentures, hence we can conclude that trauma is also a factor responsible for cancer in oral cavity[4].

Factors affecting that promote oral cancer includes, tobacco, diet , nutrition, viruses, radiation, alcohol,familial and geneticpredisposition,candidiasis,immunosuppression, syphilis, dental factors, andoccupational risks[5]. The above reported case, patient gave only history of alcohol consumption. Alcoholic beverages have been considered carcinogenic to humans causing in, tumors of the oral cavity along with tumors of GIT which include pharynx, larynx, esophagus, and liver; although ethanol has not been proven carcinogenic in animal studies, yet it is considered to be a factor[6]. The role of alcohol as an independent factor in oral carcinogenesis is still unclear but the epidemiological evidence establishes the synergistic role played by alcohol along with tobacco. Alcohol increases the permeability of oral mucosaby producing an alteration in morphology of epithelium which is characterized by epithelial atrophy, which in turn leads to easier penetration of carcinogens into the oral mucosa[7].

Management of oral cancer can be done in many ways with prolonging the life of patients with minimum discomfort. Among the approaches to the treatment of squamous cell carcinoma affecting the tongue includes surgery, radiation therapy like external beam radiotherapy and brachytherapy, coadjutant therapy with the use of chemotherapeutic agents such as cisplatin, carboplatin, 5-fluorouracil, paclitaxel and docetaxel[8,9].

Clinical and radiological assessment plays a major role in assessment of the primary tumor and areas of lymphatic drainage often understage disease in comparison with pathological assessment. Tumor control depends on two major factors, the extent and location of primary tumors along with the status of the neck lymph nodes which is the most important prognostic factor [10]. A higher risk of contralateral metastasis in patients with tumors of the floor of the mouth and the anterior third of the tongue compared to the retromolar region has been reported.In relation to tongue carcinomas, the importance of primary tumor invasion across the midline has already been stated. According to Martin, et al., 16% of the tumors crossing the midline by less than 1 cm developed contralateral lymph node relapse, and this valueconsiderably increases to 46% in cases that invade over the midline by more than 1 cm due to the involvement of contralateral lymphatic drainage [11].

There is good amount of research papers published which can help us in understanding the causes to prevent a third of all cancers in the world and with this sufficient information to enable early detection and well-timed treatment of another third of cases[12]. Until today, there is no specific biomarkers for oral cancer, yet few latest studieshave showed that elevated levels of interleukin-8 and SAT can categorize between patients with oral squamous cell carcinoma and healthy patients, with high sensitivity and specificity[13]. Research should be carried for specific biomarkers for the disease so that defining the susceptibility field for etiological factors and their interaction.