TONGUE CANCER

Tongue cancer is a tumor that occurs the bottom of the mouth, sometimes extending into the direction of the tongue and cause impaired mobility of the tongue (Van de Velde, 1999). Cancer of the tongue (anterior 2/3). Most (40%) of the oral cavity cancer is cancer of the tongue. The most frequent tumor site is on the border between the lateral edge of the central part of the rear third of the tongue (Sapp, 2004).

Tongue cancer is a malignant neoplasm arising from mucosal epithelial tissue with her cell-shaped tongue squamous cell carcinoma (stratified squamous epithelium cells), as well as some specific diseases (premalignant). This malignant cancer can infiltrate into the surrounding area, in addition can be limfogen and hematogenous metastases.

Squamous cell carcinoma of the tongue is a malignant tumor derived from epithelial mucosa of the oral cavity and is largely a kind of epidermoid carcinoma. Squamous cell carcinoma of the tongue occur due to the accumulation of genetic mutations in the epithelial cells of the tongue. These changes can be caused by exposure to mutagens, a decrease in body condition and chronic irritation. Tobacco produces a chemical carcinogen that affects the metabolism of cells. Exposure to carcinogens which can cause continuous destruction of genetic squamous cell to form cancers (Shah, 2004).

Squamous cell carcinoma of the tongue is a malignant neoplasm arising from mucosal epithelial tissue with the tongue-shaped cells stratified squamous epithelium cells (squamous cell carcinoma). Clinical manifestations of tongue cancer in children is not different from the adult. Future location of tumors in the tongue showed no differences with adults. The frequency of metastasis is higher than adults (Scully, 1992).

Etiology

Oral cancer has a multifactorial causes and a process that consists of several steps involving the initiation, promotion and development of tumors. Broadly speaking, the etiology of cancer of the tongue:

1. Tobacco: 80% of patients with tongue cancer are smokers. Risk smokers are 5-9 times more likely than nonsmokers.

2. Alcoholism: heavy drinkers had a 30 times greater risk and its effect
synergistically with smoking.

3. Viral infections in the oral cavity: Human papilloma virus (HPV), especially HPV 16 and HPV 18.

4. Oral hygiene is bad.

5. Sunburn: irritation sunlight and other chronic irritation.

6. Lifestyle: the habit of chewing betel.

Factors causing squamous cell carcinoma of the oral cavity is not known for certain, but it is multifactorial and involves extrinsic and intrinsic factors. Including extrinsic factors are external agents such as tobacco, alcohol, syphilis and exposure to ultraviolet light. While the intrinsic factors including systemic conditions such as genetics, malnutrition and iron deficiency (Regezi, 1999).

Pathophysiology

Base of the tongue plays an important role in speaking and swallowing. During the pharyngeal phase of swallowing, food and liquids are pushed in the direction of the oropharynx oral cavity by the tongue and muscles of mastication. Larynx lifted, effectively suppress the valve throat and forced food, liquid, and saliva into the throat hipopharynx.  

Although the larynx produces sound, the tongue and pharynx are the main organs that make up the voice. Loss of tissue from the base area to prevent the tongue with watertight closure of the larynx during swallowing action. This discrepancy allow food and liquid to escape into the pharynx and larynx, carefully choreographed change swallowing reflex and often resulting in aspiration. Good neurological decline and changes in the coordinated action of swallowing dangerous disease in this area can damage affects the ability to speak and swallow (Sloane, 2003).

Squamous cell carcinoma of the tongue epithelium often arise in areas that are not normal, but in addition to these circumstances and easy inspection of the mouth, lesions often grow into large lesions before the patient is finally coming to the dentist. Histologically, the tumor consists of a layer or group of cells eosinopilik are often accompanied by keratinasi coil. According to the sign histology, tumor included in stage I-IV (Broder). Rather benign lesions is the first group called carcinoma verukcus by Ackerman. In this group, tumor cells entry, papileferus mass forming on the surface. Tumors are passive on the surface area, but rarely extends to the bone and do not have children scattered. The tongue has a rich composition of lymph vessels, this will accelerate metastatic lymph nodes and lymph vessels made possible by the arrangement of interconnected right and left.

Rather benign tumor masses tend to form papiliferus with mild deployment kejaringan nearby. The most malignant tumors deep enough and rapid spread to nearby tissues with the deployment of a small surface, it looks as deep necrotic ulcers. Most of the visible lesions located between the two limits with superficial necrosis area in the center of the folded edge of the lesion and slightly protruding. Although there are great local deployment, but the children scattered remains running. Haematogenus metastases occur at a later stage (Kresno, 2002).

Description Histopathologic

Squamous cell carcinoma histologically demonstrated squamous epithelial cell proliferation. Visible cell atypia accompanied by changes in the form of rete peg processus, the formation of abnormal keratin, the addition basaloid cell proliferation, cell structure becomes irregular, and formed a tumor nest (child tumor) that infiltrate into the surrounding tissue, or forming children scattered to other organs (metastasis ).

Histologically squamous cell carcinomas are classified by the WHO into:

1. Well differentiated (Grade I): the proliferation of tumor cells in which the cells of keratin basaloid still well differentiated to form keratin (keratin pearl)

2. Moderate differentiated (Grade II): the proliferation of tumor cells in which most of the cells showed basaloid differentiation, forming keratin.

3. Poorly differentiated (Grade III): namely the proliferation of tumor cells in which all basaloid cells do not differentiate to form keratin, so unrecognizable.

Squamous cell carcinomas arise from dysplastic epithelial surfaces and histopathology are marked with an overview of the invasion of the island and a series of epithelial cells squamous carcinoma. Invasion characterized by irregularly expansion of the epithelium to the basement membrane and into the subepithelial connective tissue. Cells that invaded and a cell can go deep into the adipose tissue, muscle or bone and can degrade blood vessels, invaded into the lumina of venous and lymphatic. Often there is a severe inflammatory response or immune cell response against the invading epithelium, and the area of central necrosis may occur (Epstein, 2008).

Cancer cells in the berinvasi superficial, usually show a lot of eosinophilic cytoplasm with dark nuclei (hyperchromatic), and the ratio nucleus: cytoplasm increases. Pleomorfis seen various levels of cellular and nuclear. Squamous cell carcinoma of the product in the form of keratin and keratin pearls are abnormally keratinized cells, layered and rounded form of focus that can be produced in the epithelial lesions.

Histopathologic evaluation of the degree of similarity of cancer cells to the tissue of origin and the production is normally referred to as grading. Lesions were divided into three to four levels. Level of tumor histopathology associated with biological properties. A cancer cell is quite mature and very similar to the tissue of origin and will grow slowly and metastasize slower, called squamous cell carcinoma of low grade, first grade or well-differentiated. Cancer with celuler and nuclear pleomorphism with keratinization that little or no keratinization is a cancer that is not mature so it is difficult to identify the tissue of origin. Such cancers often enlarges rapidly, metastasizes early and called squamous cell carcinoma of high grade, grade III / IV, poorly differentiated or anaplastic. Cancer with a picture between two picture above is called moderately differentiated carcinoma (Holsinger, 2004).

Clinical Symptoms and Stadium

Etiologic factors of tongue cancer in children is controversial. Possible carcinogenic effects of tobacco and alkokhol in pediatric patients is low. Because this group is relatively short exposure time to the formation of a causal relationship. Therefore, other factors are suspected as etiologic factors are genetic predisposition, previous viral infection, immunodeficiency state, socioeconomic status, and oral hygiene.

Beginning of malignancy typically characterized by the presence of ulcers. If there are ulcers that do not heal within two weeks, then this situation can already be suspected as early in the process of malignancy. Other signs of ulcer malignant process include ulcers that are not sick, rolled edge. Higher than the surrounding areas and induration (harder), basically can nodule - nodule and peeling, the growth of carcinoma of the ulcer form known as endophytic growth. In addition carcinoma of the mouth is also seen as a growth eksofitik (superficial lesions) that can be shaped flowers kolatau papillary, easy bleeding. Eksofitik lesion is more easily recognized its existence and has a better prognosis. Squamous cell carcinoma is the most common cancer in the oral cavity are usually clinically visible as plaque keratosis, ulceration, induration edge lesions, redness, squamous cell can occur on all surfaces of the oral cavity (Rubnitz, 1997).

Symptoms in patients with cancer depends on the location. When located in the anterior two thirds of the tongue, sometimes just a rough surface, the main complaint is the emergence of a mass that often feels no pain, superficial ulcers that are not sick, ulcers gradually widened, rounded edges, gray like necrosis , When present in the posterior third of the tongue, the cancer is not always known by the patient, hard look, tend to infiltrate into the inside, and the pain experienced is usually associated with pain throat. When more severe, the tongue fixed to the surrounding tissue and can not be driven, may cause dysphagia, swelling of the neck. Cancer that is two-thirds more anterior tongue can be detected earlier than rang lies in the posterior third of the tongue. Sometimes limphonode regional metastases were the first indication of a small carcinoma of the tongue.

Symptoms in people depending on the location of the cancer. When located at the anterior 2/3 of the tongue, the main complaint is the emergence of a mass that often feels no pain. When arising in the posterior third, the cancer is not always known by the patient and the pain experienced is usually associated with pain throat. Cancer is located anterior 2/3 of the tongue is more than can be detected early situated posterior third of the tongue. Sometimes the regional lymph node metastases may be the first indication of a small cancer of the tongue.

Clinical aspects of carcinoma of the oral cavity did not show a different appearance for any age range. This is a classic sighting inflammatory lesions occurring continuously with hardening and infiltration at the edges, with or without vegetation in red or whitish. The location is most often found in carcinoma of the tongue is posterior and lateral limits of the tongue and floor of the mouth.

In the early stages, clinically tongue cancer can manifest in various forms, can be patchy leukoplakia, thickening, exophytic or endophytic growth ulcer forms. But mostly in the form of ulcers. Over time these ulcers will experience a deeper infiltration of the edge of the network who have induration.

1. The earliest sign is usually a painless ulcer that does not heal. Then enlarges and presses or tissue around the megakibatkan menginfiltrsi local pain, otalgia and pain ipsilateral mandible (Suyanto, 2010).

2. Infiltration into these muscles results in tongue movement is limited so that the bolus of food ingestion and speech impaired. This cancer can infiltrate surrounding tissues such as the floor of the mouth (floor of mouth, FOM), the base of the tongue and tonsils (Suyanto, 2010).

3. In line with the progress of cancer patients may complain of tenderness, difficulty chewing, swallowing, and speaking, cough with bloody sputum or an enlarged cervical lymph nodes. (Barasch, 1998).

Histopathologic classification

·         Histological type

No. Type Histology ICD. M

1. Squamous cell carcinoma 5070/3

2. Adenocarcinoma 8140/3

3. Adenoid cyst. carcinoma 8200/3

4. Ameloblastic carcinoma 9270/2

5. Adenolymphoma 8561/3

6. Mal. Mixed tumor 8940/3

7. Pleomorphic carcinoma 8941/3

8. Malignant melanoma 8720/3

9. Malignant Lymphoma 9590 / 3-9711 / 3

Most (± 90%) cancers originate from the mucosa of the oral cavity in the form of epidermoid carcinoma or squamous cell carcinoma with good differentiation, but can also differentiate being, ugly, or anaplastic. When the pathological picture shows a rhabdomyosarcoma, fibrosarcoma, malignant fibrokistoma, or other soft tissue tumors, need to be carefully examined whether the tumor is malignant tumors of the oral cavity completely (C00-C06) or a malignant tumor of the cheek tissue, skin, or bone that hold invasion oral cavity.

·         Degrees of Differentiation

The degree of differentiation Grade Specification

G1 Differentiation Good

G2 Differentiation Medium

G3 Differentiation Ugly

G4 Differentiation Without Anaplastic

·         Pathology reports Standard

That need to be reported on the results of pathological examination of the specimen operations include:

1. The type of tumor histology

2. The degree of differentiation (Grade)

3. TNM examination to determine the pathological stage (pTNM)

T: primary tumor

• tumor size

• invasion into the lymph vessels / blood

• radicality operation

N: a regional node

• size kgb found

• kgb positive level

• kgb number who posiif

• tumor invasion out capsule kgb

• the extra metastases nodules

M: distant metastases

Stage Classification Standard

Determining the stage of cancer of the oral cavity recommended using the TNM system of UICC 2002. The management of the therapy depends on the stage. Instead of a stage to describe the severity of the cancer disease can also be used extensive patterns of disease extension.

Stadium carcinoma of the oral cavity:
St T N M TNM FACTS
0 Tis N0 M0 tumors T0 Nothing found
                                 Tis tumor in situ
1 T1 N0 M0 T1 ≤ 2cm
                                  T2 2-4cm
II T2 N0 M0 T3 ≥ 4cm
                                  T4a
                                  T4b
Lips: infiltration of bone, n. Inferior alveolar, floor of the mouth and skin.
Oral cavity: infiltration into the bones, muscles of the tongue (extrinsic / deep), maxillary sinus, skin
Infiltration musticator space, pterygoid plates, base of the skull, a. Internal carotid
III T3 N0 M0
          N1 T1 N0 M0 There is no regional metastases
          T2 N1 M0 N1 Kgb single ipsilateral, ≤ 3cm
          T3 N1 M0 N2A Kgb ipsilateral singles, ≥ 3cm-6cm
                                     N2B Kgb multiple ipsilateral, ≤ 6cm
IV A T EACH T4 N0, N1, N2 M0
          M0 N2C Kgb bilateral / contralateral, N3 ≤ 6cm Kgb> 6cm
IV B EACH T N3 M0
IV C EACH T EACH N M1 M0 There are no distant metastases
M1 distant metastases

Extension extensive Cancer

No. Size Extension

1. Cancer Insitu

2. Local Cancer

3. Local Extensions

4. Metastases Away

5. Local Extension Accompanied Far metastases (Hanahan, 2000).

Diagnostic Procedures

1. Clinical examination

a. Anamnesa

Anamnesis by way of questionnaires to patients and their families.

1. The complaint

2. The course of the disease

3. The risk factors and etiologies

4. The treatment that has been given

5. How the results of treatment

6. How long delay

b. physical examination

• General Status

    General examination from head to toe

Decide on:

a. appearance

b. general state

c. distant metastases

• Status localist

   By the way: inspection and bimanual palpation

     Abnormalities in the oral cavity is checked by inspection and palpation with the help of a tongue blade and lighting by using a flashlight or head lamp. The entire oral cavity viewed from the lips to the posterior oropharynx. Tactile lesions of the oral cavity is done by inserting 1-2 fingers regards to the oral cavity. To determine the extent of the lesion performed by bimanual palpation. One or two fingers right or left hand is inserted into the mouth and fingers of the other hand touching the lesion from outside the mouth.

To be able inspection of the tongue and oropharynx, the tip of the tongue which has been given a 2x2 inch gauze held with the examiner's left hand and pulled out the mouth and directed right and left to see the dorsal surface, vemtral, and lateral tongue, floor of the mouth and oropharynx. Inspections could be even better if you use a mirror examiner.

Determine the location of the primary tumor, how shape, how much in centimeters, how extensive infiltration, how its operability.

• Regional Status

Palpation whether there are enlarged lymph nodes ipsilateral neck or contra Latera. If there is enlargement specify the location, number, size, and mobility

2. Examination Radiography

a. X-plain

• X-mandibular photo AP, lateral, Eisler, panoramic, occlusal, worked on the tumor
   gingival mandible, or tumor attached to the mandible

• X-lateral head shots, waters, occlusal, gingival done on the tumor, maxillary, or
   tumor attached to the maxilla

• X-Hap photos done on the hard palate tumor

• X-thorax, to determine the presence of pulmonary metastases

b. Imaging (made only on indication)

• Liver ultrasound to see metastases in the liver

• Ct-scan or MRI to evaluate tumor extension area lokoregional

• A bone scan, if there is suspected bone metastases

3. Laboratory tests

Routine laboratory tests such as blood, urine, SGOT / SGPT, alkaline phosphatase, BUN / creatinine, albumin, globulin, serum electrolytes, physiological hemostasis, to assess the general condition and operations preparations.

4. Examination of Pathology

All patients with oral cavity cancer or suspected cancer of the oral cavity must be carefully examined pathologically. Specimens should be taken from a tumor biopsy. Fine-needle biopsy (FNA) for cytological examination can be performed on the primary tumor or tumor metastases in the lymph nodes of the neck.

Excisional biopsy: when the tumor is small, 1cm, or less dkerjakan excision was wide excision as opersi definitive action (1cm from the edge of the tumor)

Incisional biopsy: or biopsy cakot (punch biopsy) using alligator forceps, when large tumors or inoperable.

Which should be examined in a histopathology preparation is the type, differentiation, and extensive invasion of the tumor. Large tumor estimated operable: Biopsy should be done under general anesthesia and can be done at the same time for a bimanual exploration to determine the extent of tumor infiltration (staging). Large tumor estimated inoperable: Biopsy is done with local anesthesia blocks the normal tissue around the tumor. (anesthesia infiltration in tumors should not be done to prevent the spread of cancer cells).

Wide diagnosis is established:

1. The first diagnosis: macroscopic picture of the cancer itself, which is a clinical diagnosis.

2. Diagnosis of complications: other diseases caused by the cancer.

3. The secondary diagnosis: other diseases that have nothing to do with cancer who suffered, but it can affect treatment or prognosis

4. The diagnosis of pathology: microscopic appearance of the cancer (Lukito, 2010).