The Ohio State University

Case Study: The Anatomy of Squamous Cell Carcinoma of the Base of Tongue

Jessica Schwab

Sectional Anatomy

Dr. Randee Hunter

April 26, 2017

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 An often-overlooked organ of the human body; the tongue plays many roles in day-to-

day life. It is essential for swallowing because it propels food toward the oropharynx from the

oral cavity. After this, the larynx elevates and compresses the epiglottis and supraglottic larynx

against the base of the tongue to force food into the hypopharynx.4 The hypoglossal nerve sits

in the base of the tongue and can be compressed by malignant tumors.4 The tongue, along with

the pharynx and larynx, are essential organs for speech. Loss of tissue from the base of the

tongue, which this patient experienced during surgery, can allow food or liquids to slip into the

pharynx or larynx and thus cause aspiration.4 This makes squamous cell carcinoma (SCC) of the

tongue very dangerous for patients because of its location to other important anatomical

structures. Any change in tongue mobility is registered as altered speech and this alteration can

come from neoplasms sitting at the base of the tongue.

Squamous cell carcinomas come from epithelial cells that line the surfaces of tissues and

cavities. Regarding oral cavity malignancy, 40% of tumors occur on the tongue.4 During the last

decade, researchers have reported dramatic increased incidence rates of SCC of the tongue in

young adults less than forty-five years old.5 Between 1992 and 2001, cancer of the oral cavity

was the seventh most common cancer in men in the United States.5 Ten years ago there were

about 7,000 patients diagnosed with tongue cancer, with over half of those being male. 4 Since

then, this incidence number has been on the increase. The relative five-year survival rate for

adults ages 20 to 44 has been reported as 64%, about 10% greater than patients older than

forty-five.5 Most young adults are diagnosed when the cancer is in a localized spot in the body;

which is a potential reason for the higher survival rate. About 46% of patients with SCC have

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metastasis at the time of diagnosis.5 In this case, the patient presented with localized cancer

but it did later metastasize.

Base of tongue carcinoma is more commonly seen in older individuals. Although

statistics are showing an increase in incidence in younger adults; old age is considered a risk

factor.4 Men are two times more likely to develop SCC of the tongue than women are.4 Chronic

alcohol abuse and smoking are the main risk factors. It is important to note that this patient

was negative for the later, as well as has no family history of cancer. Human papilloma virus is

strongly connected with cervical cancer but has also been linked with cancers of the oral cavity.

As with many other cancers, immunosuppression is also a risk factor. Prior malignancies, HPV,

and certain drugs can all suppress the immune system and make it easier for cancer to infect

the body. Other than being male, this young patient presented with no other risk factors for

SCC of the base of tongue.

The patient that this case study is centered on is a twenty-six-year-old male. The patient

has a history of one seizure two years ago, but otherwise no other significant medical or

surgical history. The patient lives in northern Ohio and works as a fork lift operator. He reports

that he has never smoked or taken illicit drugs. He drinks about 2.4 oz. of alcohol per week. The

only family medical history is hypertension in his father. The patient’s extended family is

negative for malignant disease.

The most common symptoms of SCC of the base of tongue include dysphagia (trouble

swallowing), a feeling of a mass in the throat, and the presence of a mass in the neck.4 Because

the tongue has many nerves innervating it, patients can also complain of ear pain. There is

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often a delay in diagnosis because these symptoms mock other common diseases like strep

throat or a cold. Because of a delay in diagnosis it is not uncommon for these patients to be

diagnosed at a later stage or to have lymph node involvement. Patients may also present with

bilateral adenopathy (swollen lymph nodes) in the neck and this can be a sign of lymph node

metastasis.

The patient focused on in this case study presented to the emergency room in the

beginning of September 2016. He was experiencing tongue swelling and left ear pain that

would not go away. The physician prescribed antibiotics for the apparent ear infection and gave

the patient a steroid shot for the swelling. After another week of consistent pain, the patient

was given a referral for ENT (an ear, nose and throat specialist). The patient presented his

symptoms and explained that he had a thirty-pound weight loss in two weeks. He went on to

say that it was hard to swallow and had difficulty moving his tongue. He rated his overall pain as

a 4/10.

The gold standard of oral cavity cancer diagnosis is a biopsy with a pathology report.3

Because the symptoms of SCC sometimes mock benign conditions, a sample of the lesion is the

only way to definitively prove that the lesion is cancerous. After a consultation with the ENT the

patient underwent a CT to view the area of interest (the neck) and to also check for enlarged

lymph nodes. CT scans are very helpful during the progression of SCC of the tongue because

they can show metastasis. Patients, especially those with high grade disease, will periodically

undergo chest CT scans to rule out metastasis to the lungs. PET scans are also used to check

spread to distant areas of the body. After diagnosis, surgery is then done to remove as much of

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the primary tumor as possible.3 During surgery, the doctor may add a tracheostomy tube or

PEG tube to help the patient have a better way of life.

On September 18, 2016, a CT of the neck was done and it showed asymmetry of the

base of tongue as well as an enlarged submandibular lymph node. Because of these findings on

the CT, a biopsy was done on September 22, 2016 of the lesion on the left side of the tongue.

The pathology report confirmed a squamous cell carcinoma of the tongue. This mass measured

4cm and passed anterior onto the midline of the mouth. The mass involved the entire left

lateral tongue and went past the vallecula. On September 29th, an MRI was performed and

showed a “infiltrative oral and oropharyngeal mass” with left tongue involvement. On

December 9th, a PET scan was done and showed no distant metastasis.

With most hypermetabolic cancers and high stage/grade diseases, a CT of the chest was

done to check for pulmonary spread. A chest CT done on December 12 showed hilar and right

middle lobe calcified granulomas. Granulomas are collections of macrophages that build up

when the immune system fails to eliminate a disease.1 On January 25, 2017 a fluoroscopy study

was done to see how the patient could swallow. It showed reduced tongue base retraction,

epiglottic inversion and pharyngeal peristalsis. A complete oral cavity resection was performed

after the fluoroscopy. The whole tongue, floor of mouth, mandibular lingual gingiva, base of

tongue and middle 1/3 of the hyoid bone were all removed. The right facial artery was

anastomosed, or combined, to the pedicle artery. A coupler was attached to the right facial vein

to permit regular blood flow because the disruption of the venous system during surgery. After

surgery was complete the staging of the disease was confirmed. The cancer was termed a T4N2,

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or stage 4 squamous cell carcinoma, positive for lymph node spread, of the base of tongue and

pre-epiglottic space.

On February 13, 2017, a CT with contrast of the neck was obtained. There was evidence

of tumor recurrence along the surgical margins extending into the deep neck soft tissues. There

was extension into the carotid sheaths, encasement of the bilateral carotid arteries and jugular

veins and involvement of the right supraglottic larynx. There was also involvement of the

masticator spaces and the hyoid bone. Enlarging nodules in the right upper lobe of the lung

presented concern for pulmonary metastasis. One month later a chest CT was performed to

check for cancer spread to the lungs. There was a 1cm large lesion in the right upper lobe and a

.9cm nodule in the left upper lobe. These lesions were both suspected to be metastatic and the

right upper nodule was defined as a potential second primary cancer.

The treatment protocol for this stage 4 SCC of the base of tongue was very extensive. It

involved a total glossectomy (full tongue removal), neck dissection, PEG tube and trach

insertion and external beam radiation therapy lasting seven weeks. The glossectomy and neck

dissection ensured removal of the primary tumor. Because there is usually microscopic

malignant cellular growth from cancer, the physician could not be positive that all cancerous

cells were removed during surgery. Radiation therapy to the site of the tumor bed and lymph

nodes was used in treatment to help kill any remaining malignant cells. A trach tube was

inserted into the patient’s airway to assist in breathing and the PEG tube was inserted into the

stomach for nutritional purposes. With the treatment protocol comes many unwarranted side

effects. These include skin irritation from the radiation, mouth sores, a decrease in jaw

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movement and damage to the neck blood vessels. It is important to note that in this case the

patient had two arteries anastomosed and the right facial vein had a coupler attached.

The anatomy of this case study all centers around the oral cavity and neck region. The

base of tongue is a part of the oropharynx. It is bound anteriorly and superiorly by the

circumvallate papilla, inferiorly by the valleculae and laterally by the glossoepiglottic folds.4 The

tongue is supplied by the lingual arteries.4 Nerve innervation includes the lingual and

hypoglossal nerves. These contribute to movement, sensation, and salvation.4 The structures of

the neck include the pharynx, larynx, esophagus, trachea, salivary glands, thyroid gland and

cervical lymph nodes.2 The 4cm mass that this patient presented with went past the valleculae.

The valleculae are pouch like openings at the union of the base of the tongue and the

epiglottis.2 The pre epiglottic space tested positive for squamous cell carcinoma along with the

base of the tongue. The epiglottis is located posterior to the superior thyroid notch. The

superior thyroid notch is an area where the lamina in the laryngeal prominence, or Adam’s

apple, do not meet.2 The epiglottis is elastic and projects superiorly and posteriorly behind the

tongue.

Cervical lymph nodes played a role in this case as the patient tested positive for

submandibular spread. There are around 75 nodes on each side of the neck and their job is to

filter out harmful foreign particles.2 Submandibular nodes are classified as level I because of

their superior location. They are located between the mental protuberance of the mandible

and mandibular angle.2 This location is clinically important because these nodes are easily

palpated when they are enlarged because of their superior and lateral location. Enlargement of

lymph nodes also indicates inflammation somewhere in the body.

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 At the time of diagnosis, the patient was experiencing difficultly speaking and

swallowing. The external, longitudinal and tongue muscles of the pharyngeal region all aid in

those actions. External muscles, also known as constrictors, induce swallowing.2 The

longitudinal muscles elevate the pharynx and larynx during swallowing and speaking.2 Finally,

the four muscles of the tongue aid in its movement. The whole tongue was removed from the

patient during surgery. All the tongue muscles insert onto the tongue; so, they lost their point

of insertion completely and their use is not needed in the patient anymore.

The anatomy of this case helped the physician to stage the disease. Because the lesion

measured 4cm across and it invaded the pre-epiglottic space, it was termed a stage 4. The

identification of the submandibular lymph node on the CT scan also contributed to the high

stage because stage 4 SCC of the base of tongue must have at least one lymph node involved. 4

At the time of diagnosis there was no distant metastasis; but progression of the disease lead to

eventual spread to the lungs. The chest CT showed cancerous lesions in the lungs that again

increased the severity of the disease.

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 APPENDIX WITH IMAGES LABELED:

The image below is an axial slice of the MRI obtained on September 29, 2016. This MRI

showed that there was an infiltrative oral mass involving the tongue muscles and left tongue

base down to the vallecula.

Hard palate Soft palate

Oropharynx

Masseter m. Mandible

Internal carotid a.
Mastoid process

Internal jugular v. Longus capitis m.

Sternocleidomastoid m.

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 The image below is from a fluoroscopy scan done on January 25, 2017. This was done to

evaluate how the patient swallowed. It showed reduced tongue base retraction, epiglottic

inversion and pharyngeal peristalsis.

Clivus
Nasopharynx
Sphenoid sinus

Oropharynx

Laryngopharynx

Esophagus

Tracheostomy tube

Trachea

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 Superior vena cava
Left lung, upper lobe

The image on the left is from a CT scan

done on March 13, 2017. It shows multiple

lesions that are positive for malignancy.

Ascending aorta

carina

scapula

Descending aorta

Trapezius m.

Spinous process of vertebrae

Right lower lung lobe

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 WORKS CITED:

1) Alilou M, Beig N, Orooji M, et al. An integrated segmentation and shape based

classification scheme for distinguishing adenocarcinomas from granulomas on lung

CT. Medical physics. https://www.ncbi.nlm.nih.gov/pubmed/28295386. Published

March 14, 2017. Accessed April 23, 2017.

2) Kelley LL, Petersen CM. Sectional Anatomy for Imaging Professionals . 3rd ed. St.

Louis, MO: Mosby; 2013. Chapter 5: Neck was extensively examined from this

resource.

3) Messadi D. Diagnostic aids for detection of oral precancerous conditions.

International Journal of Oral Science. June 2013:59-65. doi:10.1038/ijos.2013.24.

4) Najjar T. Malignant Tumors of the Base of Tongue. Emedicine.

http://emedicine.medscape.com/article/847955-overview#a5. Published January 6,

2017. Accessed April 23, 2017.

5) Shiboski CH, Schmidt BL, Jordan RCK. Tongue and tonsil carcinoma. Wiley Online

Library . http://onlinelibrary.wiley.com/doi/10.1002/cncr.20998/full. Published

March 16, 2005. Accessed April 23, 2017.

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