Case Report: Squamous Cell Carcinoma of the Tongue

David R. Telles, DDS

Jason Swantek, DDS

Joshua M. Abrahams, DMD

NYU- Woodhull Medical Center

Sqaumous Cell Carcinoma• Statistics

– 94% of all oral malignancies– 21,000 new cases diagnosed annually– 6,000 Americans die each year from SCC– Tobacco and alcohol is shown in the elevation of

cancer risk more than 35-fold for men who smoke two or more packs of cigarettes and consume more than four alcoholic drinks per day1

• Carcinoma of the Tongue– Accounts for more than 50% of intraoral cancers

in the US– 20% occur on anterior lateral and ventral surfaces– 4% occur on dorsum of tongue– 66% of lingual carcinomas appear as painless, indurated masses or ulcers of the posterior lateral

border of the tongue• Etiology

– No single causative agent (Extrinsic and Intrinsic Factors)– Risk Factors:

• Tobacco Smoking , Alcohol• Phenols, Radiation, Iron Deficiency, Vit A deficiency, Candidal Infection• Oncogenic viruses, Immunosuppression

78 y/o Hispanic Female

• CC: “My lower right side of my tongue hurts”

• HPI: Pt first noticed lesion approx 6 months prior which she notes has grown and become painful. Pt on presentation denied voice changes or dysphagia

• PMHx: HTN, Dislypidemia, Osteoarthritis

• Meds: Altace

• NKDA

• Social Hx: Denies Tobacco/ drug use, Hx of past chronic alcoholism when her husband was alive – 5x/wk for ~ 30 yrs – currently pt does not drink

• ROS:

– HEENT: burning tongue on R side for last with mild bleeding on palpation,

• PE:

– Erythroleukoplakic lesion on right lateral border of tongue approx. 1.5 cm x 2.0 cm

– No palpable Lymph nodes on H&N exam

Surgical Pathology ExaminationIncisional Biopsy

• 6/15/10: Pt taken to operating room for incisional biopsy of right lateral border of tongue lesion– Results: Mild, moderate, severe dysplasia, carcinoma in situ,

and superficially invasive squamous cell carcinoma

Ulcer Carcinoma

Surgical Pathology ExaminationExcisional Biopsy

• 7/08/10: Pt taken to operating room for excisional biopsy of right lateral tongue lesion– On same day of excisional biospy Panendoscopy was

performed by ENT and noted to be negative– Results: Specimen measured 2.5x2.0x1.0cm. All margins of

excision including deep margin are free of neoplasm

Tumor-Node-Metastasis (TNM) Staging

Primary Tumor Size (T)

TX No available info on primary tumor

T0 No evidence of primary tumor

T1S

Only Carcinoma in situ at primary site

T1 Tumor is less than 2cm in greatest diameter

T2 Tumor is 2-4cm in greatest diameter

T3 Tumor >4cm in diameter

T4 Massive tumor >4cm w/ involvement of antrum, pterygoid muscles, base of tongue, or skin

Regional Lymph Node Involvement (N)

NX Nodes couldn’t be or were not assessed

N0 No clinically positive nodes

N1 Single clinically + homolateral node less than 3cm in diameter

N2 Single clinically + homolateral node 3-6cm in diameter or multiple clinically + homolateral nodes, none more than 6cm in diameterN2a – Single clinically + node 3-6cm in diameterN2b – Multiple clinically + homolateral nodes, none more than 6cm in diamter

N3 Massive homolateral node or nodes, bilateral nodes, or contralateral node or nodesN3a – Clinically positive homolateral or nodes, one more than 6cm in diaN3b – Bilateral clinically + nodesN3c – Contralateral clinically + node or nodes

Involvement By Distant Metastases (M)

MX Distant metastasis was not assessed

M0 No evidence of distant metastasis

M1 Distant Metastasis is present

Stage TNM Classification 5-Year Survival Rate

Stage I T1 N0 M0 85%

Stage II T2 N0 M0 66%

Stage III T3 N0 M0 or T1, T2, T3, N1 M0 41%

Stage IV Any T4 lesion, or Any N2 or N3 lesion, or any M1 lesion

9%

Histopathologic Grading

• Histopathologic Evaluation– Tumors that closely resemble the original squamous epithelium

seem to grow at a slower pace and are slower to metastasize (Low-grade, Grade 1, or well-differentiated)

– Less differentiated tumors receive higher grades and often enlarge rapidly, metastasize earlier (high-grade, grade III/IV, poorly differentiated

• Diagnosis of SCC– Almost always made with routine light microscopy

Hyperchromatic Nuclei

Carcinoma Foci found within skeletal muscle

Treatment and Prognosis• Guided by clinical stage of the disease• Consists of wide (radical) surgical excision, radiation

therapy, or combination• Suspected local lymph node metastasis

– Radical Neck Dissection• Removal of all ipsilateral cervical lymph node groups from

levels I-V, together with spinal accessory nerve (SAN), SCM, Internal jugular vein (IJV)

– Modified Radical Neck Dissection• Removal of all lymph node groups but with preservation of one or more

nonlymphatic structures (SAN, SCM, IJV)• According to Bellinger et. al.

– no demonstrable differences in rates of locoregional control or survival between surgery and irradiation for T1 and T2 lesions. Surgical resection is typically employed for stage I and II lesions

– combined therapy using surgery and postoperative radiotherapy is indicated for stage III and IV disease.

References

• Bellingers Otorhinolaryngology: Head and Neck Surgery 16th Ed. 1996

• Neville, Oral and Maxillofacial Pathology, 2nd Edition, WB Saunders Company, 2002