Introduction

Carcinoma of the tongue is relatively common in India and forms a significant group of all the Head and Neck Malignancies as per statistics collected in Bombay.₁ It comprises of 3% of all malignancies and 30% of oral malignancies of which division between anterior 2/3 and posterior 1/3 is 3:4 according to this series.

According to European statistics the incidence of posterior 1/3 involvement is lower.₂,₈,₁₀ Although lesion is either ulcerative or proliferative on an easily visible organ with exceptional mobility, it is a sad fact that many patients present in late stages. Hence, even though the disease is curable and has a high five years survival rate, presenting in the late stages, reduces five years survival rate. According to Frenzel, though tumor size does not have direct correlation with prognosis, larger tumor size is associated with shorter survival.₁₃

The modalities of treatment vary according to the type of lesion, according to the stage at which the patient presents himself for treatment, involvement of mandible and most importantly with the presence of local and distant metastasis. Anaplastic and poorly differentiated tumors make for poor prognosis. Both radiation and surgery have their advocates and the treatment changes with the facilities available and the views of the surgeon or radiologist concerned. Chemotherapy, as in most head and neck malignancies, plays a secondary role to radiation and surgery.¹⁰

However in the stage III and stage IV tumors, where spread has occurred to the mucosa of floor of mouth, buccal mucosa it may be used in conjunction with radiation or prior to surgical excision, with an over view to reduce the post - operative recurrence.¹³

Material And Methods Of Collection

This is a retrospective study of cases of cancer of the tongue, from Masina hospital in Bombay over the past 6 years from September '96 to August ‘2002. As our hospital does not have facilities for radiation, patients who are sent for radiation as primary modality of treatment tends to attend follow up in the radiation centers only.

Follow- up of operated and radiated patients has been available regularly. The data has been collected regarding all cases that were diagnosed as cancer of the tongue and confirmed on biopsy.

The data has been classified as --

1. Sex Incidence

2. Age Incidence

3. Presenting symptoms and signs.

4. TNM Classification and Staging.

5. Histopathology and clinical Correlation.

6. Modality of treatment offered.

7. Type of procedure.

8. Surgical complication, outcome.

9. Final outcome.

Every patient who was clinically diagnosed as cancer of tongue was admitted to the hospital on the first visit, to facilitate early definitive treatment. The patient was clinically staged and biopsy taken under local anesthesia, but if necessary (i.e. posterior 1/3 growths) using general anesthesia. General condition, especially status of nutrition and hydration was noted. Patients presenting late, had dysphagia, nutritional and hydration problems.

If needed a nasogastric tube of No. 16-20 was passed and feeding commenced. Patient's fitness to undergo major surgery or radiation was assessed and necessary investigations were done. Cardiological, general medical and condition of the chest was evaluated especially keeping in mind that patient is likely candidate for major surgery. The staging of the tumors was done according to the UICC-TNM classification for oral cavity tumors.

Discussion

Figure 1

Table 1: Habits

More than half of our patients were addicted to both paan and tobacco chewing as well as smoking. Almost all of our cases needed dental attention as they had marked carious teeth and were advised partial or total dental extraction pre-operatively. One of our patients, who was operated for partial glossectomy had a recurrence near the carious tooth post-operatively which he had refused to get extracted.

Incidence of spicy food could not be assessed satisfactorily, while syphilis and alcohol did not feature prominently. Amongst our cases the incidence of tobacco chewing with lime was noted and it was found that the patients who kept tobacco bolus in the mouth for many hours at a particular place were more prone to develop malignancy at that point.

Figure 2

Table 2: Sex Incidence according to age

The sex incidence found by the European authors is about a decade higher than what we have found.₆,⁸ This may be related to less life expectancy in India. Patel et al. have reported tumors in children, but we have not encountered any in our series.₄

Figure 3

Table 3:Incidence according to anatomical site

Growth was seen more commonly on margins, and only one swelling was seen on tip. The western authors have reported higher incidence of anterior 1/3 especially in female patients.⁶,⁸,¹⁰

Figure 4

Table 4: Histological classification

Well-differentiated squamous cell carcinoma was the commonest in our series. Incidence of anaplastic carcinoma (un-differentiated) in our series is lower than that reported by Lucas and Frenzel.¹³ Thus we see that though the tongue is composed of epithelium, muscle, salivary glands and fibro fatty tissue, malignancy occurs almost exclusively in the epithelium. No sarcoma was seen in 110 cases while only one adenoid cystic carcinoma was seen.

Below is a Table illustrating the selection of patients for surgery. About 40 % patients were taken for surgery while 36% were subjected to radiation.

Table 5: Treatment a, b & c

Figure 5

This does not include 18% of the patients who refused the surgical treatment. Some patients received at least 2 modalities together i.e. Surgery + radiation or Surgery + Chemotherapy or Chemotherapy + radiation.

These figures when compared to the European statistics show that our Center has a preference for surgical management.⁶,⁸,¹⁰ This is partly due to the fact that we have no facilities for radiation. Surgery was offered as a modality of treatment to the patients according to stages. Their division was as follows:

Figure 6

This compares well with Yarrington's series only difference being stage-III lesions.₉ As the patients reach very late in course of the disease to the hospital the percentage of stage-I lesions seen at the Institute was less than that of western statistics of white Hurst or that of Frenzel.

As operative procedures, the cases can be divided into

Figure 7

This shows preponderance of major procedures and need of reconstruction in a greater number of patients.

This is partly explained by the fact that more no. of patients were taken up for surgery in stage-III, a more advanced stage. Another fact that is to be remembered here, is that no. of posterior 1/3 lesions operated in this series is large.

As the general nutritional state of the Indian patients is poor as compared to the European or American patients, it is quite expected that the post operative complications would be more in our series than in European series.¹⁰,₁₄ Also no. of advanced cases operated in this series is larger than European series like Yarrington's series leading to more complications.⁹

Table 6:Complications a, b &c

Figure 8

Figure 9

b. Major Complications

Some patients had more than one of the complications. Total mortality at the end of the 15 days (i.e. the deaths that could be directly, or indirectly were attribuTable to surgery) was 4 patients, making about 10%. Total 9 patients had major complications i.e. about 20 % of the operated patients. These rates are higher as compared to the other series due to reasons stated above. There is a scope of improvement with improving the post-operative care by introducing more direct monitoring as facilities improve.

Figure 10

c. Minor Complications

Some patients had more than one complications of the same group. Total no. of patients who had minor complications were 12.

Figure 11

Table 7:Survival Rate

This is a stage-wise breakup of the patients relating to the survival. As a large no. of patients were operated in S3 an advanced stage. 3 years survival was also included. Thus total average 5 years survival comes to about 33 %, which is quite low as compared to Frenzel & Lucas ¹³ who reported 47 % cure rate and Mandelson who reported 76% cure rate. But if S3 lesions are excluded the results of this series are comparable to Mendelson's series.₅

Stage-III patients who otherwise may not have lived for more than 2 years have been shown to have more than 50% of 3 years survival rate, which may be significant. Thus patients who present late at Stage-III can also be offered some hope with ultra-radical surgery followed by radiation.

Frenzel & Lucas have divided the survival in relation to presence of neck-nodes.¹³ He reports 16% survival in presence of neck nodes as compared to our series, which shows 28% survival rate in stage-III i.e. with nodes.

Figure 12

This Table shows that -

1. Survival of the patients is directly related to tumor size and as size increases the survival falls sharply.

2. Presence of nodes is an ominous sign and suggests grave prognosis regardless of the mode of treatment.

This confirms the finding of previous workers like Mendelson and Lucas & Frenzel¹³ and Merchetta.¹⁴

Conclusion

Before coming to conclusion, it is necessary to keep certain facts about this series in mind.

1. Though average age incidence of the patient is lower than the European series,10 however due to low life expectancy in India and advanced stage of malignancy at the first visit, physiological age on an average can be considered higher.1,4

2. The patients presented late with cachexia, and loss of weight. Common presenting stages are SII or SIII. This affects the prognosis gravely.

3. Facilities for post-operative care are limited in this Institute and also no radiation facilities are available.

4. Incidence of posterior 1/3rd of tongue involvement with malignancy in this series is significantly high. Making the prognosis worse as these tumors are known to be more difficult to treat.

Keeping these limitations in the mind following conclusion can be drawn from this study.

A. Common presentation of carcinoma of tongue is in Stage-II. B. Cancer of posterior 1/3^rd of tongue was observed as equal or more than anterior 2/3^rd in this series. C.Surgical treatments of late stages of cancer of tongue both anterior 2/3^rd and posterior 1/3^rd are rewarding. D. Surgery is the treatment of choice for patients who present at later stages of disease followed by radiation if necessary. Though no strong dogma is expressed about the modality of treatment, we favor surgery as a treatment for carcinoma of tongue.