J. Maxillofac. Oral Surg.
(Oct–Dec 2014) 13(4):394–400
DOI 10.1007/s12663-013-0566-8
REVIEW PAPER
New Management Strategies of Oral Tongue Cancer
in Bangladesh
Jachmen Sultana • Abul Bashar • Motiur Rahman Molla
Received: 10 December 2012 / Accepted: 7 August 2013 / Published online: 30 August 2013
Ó Association of Oral and Maxillofacial Surgeons of India 2013
Abstract
Introduction Malignancies of the tongue represent one of
the greatest management challenges for the maxillofacial
surgeons as well as oncologists, because of the adverse
effects of treatment on oral and pharyngeal function, the
eventual quality of life, and the poor prognosis of advanced
disease. Therefore, it is important to use judgment and
experience in determining the best method of treatment.
Material and methods We reviewed forty cases of oral
tongue cancer patients admitted in the Dental and Facio-
Maxillary Surgical Oncology department in National
Institute of Cancer Research and Hospital, and department
of Oral and Maxillofacial Surgery, Dhaka Dental College
and Hospital, Dhaka, Bangladesh, during the past four
years and followed till the lesion healed or recurred and
followed later on upto two years. All cases were thoroughly
examined, investigated with routine blood examinations
and radiography of the involved region. Preoperative
biopsy of the lesion and staging was done in each and every
J. Sultana (&)
Department of Oral and Maxillofacial Surgery, Dhaka Dental
College and Hospital, Dhaka, Bangladesh
e-mail: dr.jachmen007@yahoo.com
J. Sultana
Elysia, House # 24, Flat # A-2, Road # 6, Dhanmondi,
Dhaka 1205, Bangladesh
A. Bashar
Department of Neonatology, Bangabandhu Sheikh Mujib
Medical University, Dhaka, Bangladesh
M. R. Molla
Department of Oral and Maxillofacial Surgery, Bangabandhu
Sheikh Mujib Medical University, Dhaka, Bangladesh
123
case. Postoperative biopsy was taken where there was a
doubt about the possibility of recurrence.
Results Squamous cell carcinoma (well differentiated) is
by far the most common malignancy of the oral tongue.
Generally a correlation is recognized between tumor size,
nodal presence, metastasis, and eventual prognosis. When
surgeons detect oral tongue cancer at an early stage, they
can often treat it with surgery or can, often treat it with
surgery or radiation. In later stages the cancer may require
a combination of surgery, radiation and chemotherapy.
Conclusion Standard and uniform protocol has not been
explored till now for the practice in our country. So current
management strategies of oral tongue cancer cannot be
underestimated.
Keywords Tongue Cancer
Management
Oral
Care
Prevention
Bangladesh
Introduction
One of the most common site for intraoral carcinoma is the
tongue. Though there is no recognized survey on tongue
cancer in Bangladesh, but 30 % of head and neck cancers
in nearby country like India constitutes of tongue cancers
[1]. These tumors most frequently arise from the lateral
aspect (85 %) of the oral tongue. The majority of tongue
cancers are squamous cell carcinoma and are well differ-
entiated, while poorly differentiated varieties are rare [2].
These arise from the lining that covers the muscles of the
tongue. Studies shows that tongue cancer usually occurs
after the age of 40, with men affected more than women
(10 %) [3–5]. The condition may appear as a lump, white
or red spot or ulcer. Pain is a relatively late occurrence as a
rule [3]. Though exact etiology of tongue cancer is still
J. Maxillofac. Oral Surg. (Oct–Dec 2014) 13(4):394–400 395

unknown, but several risk factors have been identified.

Chewing tobacco, pan, betal nuts or quid is very common
in parts of Asia and is known to be a main cause of oral
cancer including tongue [5, 6]. The etiological factors of
oral squamous cell carcinoma (OSCC) are different in
different areas of the world [7]. The common site of oral
cancer also differs due to some habit. Due to some geo-
graphic distribution and socio-economic condition, the rate
of oral cancer is high in our country than the developed
countries [8, 9]. So current management strategies of oral
tongue cancer cannot be underestimated.
The tongue is divided into two parts for the purpose of
diagnosis and treatment of tongue tumors. The first is the
oral or mobile tongue (front two-thirds of tongue), cancers
that develop in this part of the tongue come under a group
of cancers called mouth (oral) cancer. The other is the base
of the tongue (back third of tongue), cancers that develop
in this part are called oropharyngeal cancers. Tumors of
each of these areas present slightly differently and are
treated differently [5]. Predictors of outcome of tongue
cancer still remain unknown. Standard and uniform pro-
tocol is not explored till now for the practice in our
country. This guideline has been written to assist doctors
and other health care providers in the recognition, diag-
nosis and management of oral tongue cancer patients.

Initial Evaluation

Examination of the Oral Cavity

Hold the tip of the tongue with a piece of gauze by the left
hand and pull it out to inspect and palpate the dorsal sur-
face of the tongue as well as lateral borders. Then turn it
upwards to allow examination of the ventral surface of the
tongue and floor of the oral cavity. The doctor will ask the
patient specific questions about symptoms and make initial
evaluation by medical and physical examination (cancer
Fig. 1 Technique of examination of the oral tongue and common site
screening exam) (Fig. 1).
of tongue cancer
1. Know the risk factors associated with tongue cancer
Diagnosis
e.g. men over the age of 40, tobacco and betel nut
users, people who consume excessive amounts of
Doctors use a variety of diagnostic tools to confirm the
alcoholic beverages.
disease and to determine the extent of involvement, along
2. Look for red, white or red and white patches or any
with initial clinical evaluation before choosing a treatment.
sores that do not heal for long time or lumps in the
These include:
tongue or a lump on the neck.
3. Complain of pain on swallowing or of any other 1. Tongue biopsy—Incisional, Punch biopsy, Fine Nee-
constant numbness or pain or difficulty in moving the dle Aspiration (FNA) biopsy and microscopic
tongue or jaw. examination
4. Check for any unexplained bleeding, bad breath. 2. FNAC of neck lymphnode or biopsy and microscopic
5. Feel for loose or painful teeth or dentures that may not examination
fit well. 3. X-rays (OPG, Chest X-ray)

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4. CT scan (CAT scan)

5. MRI (Magnetic Resonance Imaging)
6. Ultrasound scan
7. Bone scan
8. Radionuclide neck scanning (SPECT, PET)
9. Assessment of disease by using TNM, Broder’s and
Anneroth’s multifactorial classification (staging
system).

Goals of Treatment

The primary goal of treatment is to treat primary tumor in

the oral tongue, control neck disease (nodal metastasis) and
preserve function of the tongue as much as possible [10].
The tongue has the reputation of being a site from which
metastasis to the neck nodes occurs early and frequently
[3]. The incidence of lymph node metastases is propor-
tional to both the tumor T-stage and its depth, and there is
also correlation between certain histological grades of the
tumour and lymph node metastases [2]. Different treatment
protocols and technologies are used to treat oral tongue
cancer, which often includes surgery, chemotherapy (newer
chemotherapy drugs), radiotherapy (IMRT, CHART),
others—biological therapies, gene therapy, REOLYSIN (in
advanced cancer), Light therapy (PDT or photodynamic
therapy)[11]. The ultimate long term goal of treatment is to
prevent recurrence (local or distant), to reduce or prevent
complications and to prolong survival.

Principles of Treatment of the Oral Tongue

When surgeons detect oral tongue cancer at an early stage,

then can often treat it with surgery or radiation. In later
stages the cancer may require a combination of surgery,
radiation and chemotherapy [10] (Fig. 2).

Standard Treatment Options [2]

In Bangladesh in different specialized Maxillofacial Sur-

gery centers the most common protocol of treatment of oral
tongue cancers are same with negligible modifications
being wide surgical resection, resection of floor of mouth
musculature, removal of bone and associated muscle
attachments and the sacrifice of both sensory and motor
cranial nerves along with or without neck dissection.

Carcinoma of the Tip of Tongue

Stage I: Mode of treatment is surgery (wide excision): Fig. 2 Common tongue pathology, surgical management and post-
Tip of the tongue is excised perorally in a V-shaped operative recurrence

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fashion with a margin of at least 1 (one) centimeter and a
new tongue tip made by primary reconstruction.
Stage II or larger T1 lesions: Wide surgical excision or
radiotherapy of the primary site and consideration
should be given to irradiating the neck also.
Carcinoma of the Dorsum of the Tongue
Stage I: Mode of treatment is surgery (wide excision) or
irradiation. If the tumor is less than 2 cm in diameter
excision would be transoral in an ellipse and with a
margin of at least 2 cm.
Stage II: For larger tumors treatment of choice is, an
extensive surgery or radiotherapy or a combination of
both, along with neck dissection. But in order to preserve
speech and swallowing function of the tongue, most of
the cases radiation therapy is preferred.
Stage III: External beam radiotherapy with or without
interstitial implant or in advanced cases palliative
irradiation is given.
Carcinoma of the Lateral Border of the Tongue
Stage I: Partial glossectomy or interstitial irradiation
Stage II: Hemiglossectomy to subtotal glossectomy or
external beam radiotherapy (in selected cases).
Stage III: Subtotal glossectomy, here only a stump of
tongue above the vallecula is spared, along with base of
the tongue on the contra lateral side or Total glossec-
tomy and postoperative radiotherapy.
Principles of Treatment of the Neck
Treatment of the neck is a highly controversial point. But
based on the high incidence of occult neck metastases in
the clinically No neck 50 % [2] prophylactic or elective
neck dissection (usually supraomohyoid neck dissection) is
advocated even in T1No and T2No cases. There is less
controversy concerning the management of stage III and
stage IV (massive primary or neck), combined surgery and
radiation are most often employed [12]. Tumors that have
spread to the lymph nodes on one or both sides may need
selective or radical neck dissection. It lowers the risk of
cancer recurrence. Then a course of radiotherapy help to
get rid of any cancer cells left behind [5].
Multidisciplinary Approach
Multidisciplinary specialists can develop a unique treat-
ment plan for each patient, with different modalities of
treatment combined with or without surgery. Team
397
members are dental hygienist, dentist, oral and maxillofa-
cial surgeon, oncologists (surgeon, radiation specialist,
chemotherapist), nutritionist, psychiatrist or psychologist
and social worker.
Surgery
Surgeons use the latest techniques to minimize the loss of
function of the tongue and surrounding structures. Surgery
for tongue cancers depends on the tumor size, type, loca-
tion and depth [2]. Clinical evaluation of stage of disease is
often difficult in cancers of the tongue and therefore, extent
of resection is best decided at the time of operation [1]. In
case of early cancers that, denotes cancers which have not
spread beyond the primary site, it can be removed transo-
rally, adequate surgical margins are crucial at the initial
excision [12]. If the tumor extends deeply to involve the
underlying muscles, the surgeon may remove the nearby
neck nodes (prophylactic neck dissection) with moderate
excisions of tongue, occasionally hemiglossectomy is
needed [13]. However larger lesions (T3 and resectable T4)
will require mandibulotomy for access and resection. The
lesions which encroach the gingiva or superficially extend
over it, should be treated with marginal mandibulectomy
for oncologic clearance. In cases of gross involvement of
mandible, composite resection will be required in con-
junction with selective or radical neck dissection. The
extent of mandibular resection will depend on extent of
bone involvement [1].
Reconstruction and Rehabilitation
Depending upon the size, location and spread of the cancer,
the treatment team can determine whether reconstructive
and plastic surgery is necessary or not. Usually oral and
maxillofacial surgeons, reconstructive and plastic surgeons,
otorhinolaryngologists restore physical appearance and
function of the tongue and surrounding structures. Usually
a peroral large wedge resection to hemiglossectomy defect
can be closed primarily. However, subtotal glossectomy for
advance (T3 or T4) will require repair of the defect by
myocutaneous flap in order to achieve the closure [1].
Patients who need rehabilitation after surgery or radiation
therapy will find help from dietitian, speech therapist,
swallowing therapist, physical therapist, occupational
therapist and psychotherapist.
Radiation Therapy
Radiation therapy involves the use of external beam
radiotherapy (electron beams), or interstitial brachytherapy
(radioactive isotope)[2, 13]. Radiation therapy is an alter-
nate to surgery in early and intermediate size tumours of
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the anterior tongue. Radiation therapy is usually started
4–6 weeks after the surgery. The postoperative radiother-
apy dose commonly ranges between 55 and 65 Gy [1]. To
minimize loss of function of the tongue and normal sur-
rounding structures such as mucous membrane and salivary
glands [11] IMRT (Intensity modulated radiotherapy) and
CHART (continuous hyperfractionated accelerated radia-
tion therapy) irradiation is advocated.
Brachytherapy
Brachytherapy is a technique of radiotherapy selectively
used in the treatment of mainly T1 and T2 lesions. Low-
dose-rate (LDR) brachytherapy is frequently chosen for the
treatment of stage II mobile tongue cancer [14]. However
little is known about the biological mechanism underlying
this therapy. LDR may overcome the radioresistence of
non-cycling and hypoxic cells [15]. French studies at
Creteil and Nancy have shown that interstitial brachyther-
apy alone at a dose of 65 to 70 Gy is preferable (for T1–T2
lesions) and the neck can be observed for surgical salvage
in case of nodal recurrences. The commonly used radio-
isotopes are Ir-192, cs-137, I-125, Pd-203. There are dif-
ferent ways of implanting the radioactive sources. The
Paris system is most widely used in head and neck cancers
[1].
Chemotherapy
Medical oncologists administer chemotherapy when the
oral tongue cancer has spread to lymph nodes or other
organs in the body, usually in stage II cancers with surgery
and in stage III and IV cancers with radiotherapy. Che-
motherapy is commonly administered intravenously and/or
intramuscularly or orally. Some drugs are used for injecting
directly into the arteries [16] that supply the cancer or in
intralesions. These cytotoxic drugs destroy cancer cells. To
Table 1 Commonly used protocols of cytotoxic drug combinations
Protocol I
Cisplatin 25–30 mg i.v. (1 h inf) d 1–3
5-Fluorouracil 500–750 mg i.v. (cont.inf) d 1–3
Bleomycin 15 mg i.v. (bolus) d 1 followed by
16 mg/m2 (cont.inf) d 1–3
To be repeated every 3 weeks
Protocol III
5-Fluorouracil 750 mg/m2 i.v. (cont inf) d 1–4
To be repeated every week up to 12 weeks then review
Out of them Cisplatin and 5-Fu with or without methotrexate and bleomycin remain to be the most preferred regimen and a total of 3–4 cycles
has been reported in case of stage II tongue cancers, 4–6 cycles in case of stage III, IV tongue cancers [1, 6, 18]
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date, various regimens have been reported with variable
response rates and duration of response [1]. Few commonly
used protocols used in Bangladesh are given in Table 1.
Biological Therapies
Biological therapies are treatments made from naturally
occurring body substances. There are many different types
of biological therapies like monoclonal antibodies (cetux-
imab and zalutumumab) and cancer growth blockers. Both
monoclonal antibodies block the epidermal growth factor
receptors (EGFR) on cancer cells. Scientists hope that
blocking these receptors will stop the signals that tell the
cancers to grow. Now cetuximab is used with radiotherapy,
for locally advanced squamous cell head and neck cancer,
if platinum-based chemotherapy (such as cisplatin or car-
boplatin) is not working or could not be used. Zal-
utumumab is also under trial. Cancer growth factor
blockers like tyrosine kinase inhibitors (TKIS) e.g. Iressa
[11] and lidocaine which also act by blocking epidermal
growth factor receptors, are also under trial [17].
Gene Therapy
OncoVEX, ONYX-15 are genetically engineered viruses,
which are able to kill cancer cells, but not normal healthy
cells. Now researchers are using it in combination with
radiotherapy and chemotherapy drugs like 5FU and cis-
platin [11].
Reolysin (in Advanced Cancer)
Currently a virus called Reovirus is being used, which is
able to kill cancer cells when injected directly into the
tumour. Reovirus in combination with radiotherapy or
chemotherapy like paclitaxel or carboplatin is under trial
[11].
Protocol II
Paclitaxel 260 mg/m2 i.v. (3 h inf) d 1 Caboplatin 450 AUC i.v.
(30 min inf) d 2
To be repeated every 3 weeks
Protocol IV
Ifosfamide 1,500 mg/m2 i.v. (30 min inf) d 1–5 with mesna uroprotection
Cisplatin 10 mg/ms2 i.v. (30 min inf) d 1–5
To be repeated every 4 weeks
J. Maxillofac. Oral Surg. (Oct–Dec 2014) 13(4):394–400
Light Therapy (Photodynamic Therapy or PDT)
Using light treatment to kill cancer cells helps to shrink or
slow the growth of the cancer and relieve symptoms. So it
may be useful, as a palliative treatment in patients with
advanced head and neck cancer who are not able to have
any more standard treatment [11].
Complication and Management
Problems usually may be related to surgical treatment of the
primary tumor or radiation treatment or chemotherapy. The
major functional consideration with tongue resection results
in significant mobility problems and dramatic changes in
articulation, as well as aesthetics, swallowing, nutritional
status and psychosocial function. Radiation treatment causes
acute mucosal changes, erythema and edema to frank
necrosis and breakdown (mucositis), candidiasis, loss of
taste or altered taste, dysphagia. Late mucosal changes
include dryness, atrophy telangiectasia, sclerosis and
chronic edema. Late salivary gland changes range from
hyposalivation to asilorrhoea (xerostomia). Trismus is yet
another manifestation of progressive muscle fibrosis sec-
ondary to radiation therapy of the facial region. It is most
commonly a late complication of therapy, often observed a
year or more after completion of treatment. Further it can
cause rampant dental caries, osteoradionecrosis. In addition,
complications associated with chemotherapy are nausea,
vomiting, diarrhoea, stomatitis haematologic toxicity, renal
toxicity, shortness of breath, hypertension. Secondary
effects include dehydration and malnutrition [18]. Recent
research suggests that Inj. Amifostine a few minutes before
radiotherapy helps to protect against the harmful side effects
of chemotherapy and radiotherapy like xerostomia. Some
studies also suggest that acupuncture appears to help with
dry mouth, following radiotherapy and for pain, following a
neck dissection. Further, acupuncture and moxibustion help
to relieve the symptoms of lymphoedema following surgery
or radiotherapy treatment but these are under trial [11, 13].
Oral Care Considerations
In patients with mucositis, irrigation or rinsing with bland
rinses: 0.9 % saline solution (1 tsp of table salt to 32 oz of
water) or sodium bicarbonate solution (1 tsp in 8 oz of
water) or salt and soda (‘ tsp of salt and 2 tbsp of sodium
bicarbonate in 32 oz of warm water) should be performed
every 2 h for 1–2 days maximum, since chronic use may
impair timely healing of stomatitis. Moisturing can be
achieved with water-soluble lubricating jelly, cellulose film-
forming agents for covering localized ulcerative lesions (e.g.
399
hydroxypropyl cellulose, coating agents such as milk of
magnesia, sucralfate suspension combined with topical
anesthetic agents may provide topical analgesia [19]. To
relieve pain, topical anesthetics, systemic analgesics
(including opioids) are used. Intraoral use of capsaicin top-
ical lotions and creams (0.025 and 0.075 %) is under trial
[20]. Chlorhexidine gluconate 0.12 % oral rinse has been
used in combination with fluoride gel to control cariogenic
flora [21]. Management of xerostomia includes the use of
saliva substitutes (oral rinses containing hydroxyethyl-,
hydroxypropyl-, or carboxymethyl-cellulose) which are
temporary palliative agents used with oral care protocols.
Prevention
Specific Measure
1. Avoid using tobacco in any form.
2. Be sure that dentures fit properly and edges of teeth are
smooth.
3. Avoid heavy use of alcoholic beverages.
General Measure
1. A diet high in fresh fruit and vegetables reduce the risk
of mouth cancer.
2. Some scientists believe that antioxidant vitamins A, C
and E and minerals supplement may help to prevent
cancer.
3. Chemoprevention: There are two groups of drugs in
clinical trials i.e. cyclooxygenase-2 inhibitors (COX-2)
and retinoids (vitamin A) which help to prevent tongue
cancer.
4. Established tongue cancer is prevented from spreading
or recurring by:
Completing the full course of surgical, radiation,
and/or chemotherapy treatments as ordered by the
doctor.
Maintaining good oral hygiene, taking good care of
teeth and gums, and having regular dental checkups,
particularly if the patient wears dentures.
Visit the doctor immediately if a return of any
previous symptoms, such as a lump or ulcer on the
tongue that does not heal, but worsens and spreads is
noticed.
Conclusion
To increase public awareness continuing educational
campaigns are needed at community and national levels
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and routine dental check up should be instituted. Dental
practitioner can play a vital role in cancer prevention and
early diagnosis. Early diagnosis is critical if patients are to
be cured. Further treatment modality should be such as to
decrease the morbidity to the patient as well as to decrease
or perhaps obviate the chances of any recurrence [22].
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