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Lingual Carcinoma - Management and Rehabilitation

Jan 13 | 1:30 PM

In India, oral cancer affects 20 per 1,00,000 population, accounting for about 30% of all types of cancer. The most common etiological risk factors for oral cancer are severe alcoholism, tobacco overuse (cigarettes, smokeless tobacco, betel nut chewing), and human papillomavirus (HPV) infections. Join the Medflix exclusive discussion with Dr. Sharad Desai, Director at Mahatma Gandhi Cancer Hospital, as he walks through the treatment and rehabilitation plan for lingual carcinoma. Note: Certificate of attendance included!

[Music] hello good evening everyone i am dr samadhnya i welcome you all on behalf of team netflix and today we have with us dr shara desai who is a chief surgeon and director at mahatma gandhi cancer hospital mirrors serve as the past president of ima mirrors and sir is the ex-secretary of indian association of surgical oncology he's the managing director at shift cancer institute private limited mirrors and service the secretary of go karma oncology association and medical trust welcome sir thank you so good to have you again [Music] i think i will go directly to the presentation oh thank you so much over to you sir uh thank you so much so uh friends i'm back again last time we did a session on colorectal cancer and today we'll be talking on a more common cancer in our continent i mean in our country and in southeast asia cancer of the tongue or lingual cancer as it is uh alternatively known as i am dr shiraz and as some of the introduced i am the director of the math by the cancerous before we i begin my talk let me uh have it just a question like it's a poll question what is the most important function of the term so maximum people have answered mastication and deglutination okay so friends the tongue was given to us from god for mastication and degradation our tank is there almost in most of the mammals and most animals but as you all know it is not specifically for speech or taste speech and tests are alternative functions or additional functions which the tank has but the most important function of the trunk is mastication and depletion this you will only realize once you have don't have the term so ah as far as licking is concerned it's not a major function so thank you guys and warm welcome again so let us look at the tongue the tongue basically in the mouth is the leader like it is the main thing uh main active uh muscle and the main active organ of the oral cavity and it it is a hard worker most whatever the oral cavity does is mostly because of the tongue so it is something like a lay worker and it it works day in and day out and it it is one of the most mobile structure in the human body and definitely it is a hero because it tongue has got a lot of emotional appeal and whatever people talk about the oral cavity they describe it as far as the tank is concerned so whatever comes from the mouth is something like they say it's as it comes from the tongue the tongue is the advanced system of the oral cavity so it controls the old cavity whatever the activity is being done in the oral cavity so most of the activity whether spitting whether it's eating whether it's degradation mastication almost everything is controlled by the time so without the tongue all these functions would be rendered ineffective if not useless [Music] now as a guesswork i am asking you the second question for the poll what are the most common sides of tongue cancer so let me see how many of you are aware of the tongue cancer incidence and where all it occurs so we have 116 69 of wood for lateral [Music] [Music] mostly on the lateral border and it's very less common on the dorsum of the tongue tip of the tongue again is very less common based on again a little bit of a different dictionary but most of the time cancers occur on the natural water so as you all know we in my hospital we do at least around 70 to 80 cases per year that is about 5 to 10 cases per month and 80 percent of them are on the lateral border and 80 percent occur on the anterior tongue with about 20 occur on the posterior tongue that is the posterior one third is called the base tongue now what are the causes of tongue cancer so basically uh trunk cancer is very much prevalent in india it's prevalent in the south asian uh southeast south asian continent that is pakistan india bangladesh then nepal sri lanka and all these countries basically because a lot of people are addicted to tobacco that is in the chewing form and also arachnid so these two uh particular uh eat a substances are prone to cause lung cancer they they are also prone to cause a lot of other cancers of the other cancers of the oral cavity but more specifically in a tang and the buccal mucosa is very common due to tobacco and direct also alcohol also adds to this uh positive factors apart from that in our continent most of these people maintain a very poor hygiene especially because they eat a tobacco all the day where they don't have even wash or clean the mouth and another indication of tongue cancer is a sharp tooth which goes on constantly irritating the lateral border of the tongue so if a tongue particularly keeps on irritating or a particular section of the tongue and then what happens is there is it scars there is a lot of trauma occurring at that particular site and because of trauma there will be uh injury to the mucosa and after the injury there are repetitive mechanisms going on there is new growth a lot of growth factors occurring there and in one of those cells undergoes a malformation and this can lead to tongue cancer the little uncommon cause of in our country is hpv infections not very uncommon but especially in those people who do not eat tobacco and all that because of hpv infections many of these people keep on getting tongue cancer this is especially in ladies who don't have uh tobacco addictions we tend to find out hpv infections now looking at the histological features you can see that this lung cancer more or less almost always is commercial carcinoma so that's the the main epithelium of the oral cavity the squamous cell epithelium and the origin because of uh is from this epithelium and it is squamous cell group predominantly cause chromosomal customer uncommonly adenocarcinoma adenoid cystic carcinoma and other rare salivary carcinomas can occur in the water but these are little uncommon and these usually arise from cells or from ducts uh which for from the minor salivary glands it's very rare to get sarcomas but once in a while at least one or two per year we usually see some sarcoma [Music] so this is a classical picture what we usually see as you can see here we tend to see a growth in the lateral border of the tongue if it is a little mobile then it is amenable to therapy and this is a very unpleasant sign which keeps on coming in our outpatient department and we are sad to say that the incidence has still not fallen despite a lot of government rules laws and regulations which where they are trying to curb tobacco intake but still there is no uh decrease in the incidence of oral cavity cancers and especially tongue cancer now when it comes to a patient comes to us we just evaluate him we evaluate him for treatment so basically what we do is first we inspect the tongue movements the lesion how far it is whether we can see any normal mucosa behind the lesion a normal muscle in front and below the lesion and if there is good amount of mouth opening what happens is these people who usually eat tobacco also are addicted to uh supari or aryakanen and because of which they undergo a kind of fibrosis a special fibrosis in the oral cavity that is called the submucous fibrosis with the submucous fibrous what happens is there is fibrosis beneath the mucosa and this constricts and it strongly holds the mucosa tightens it and it prevents the jaws from opening white so what happens is because of poor mouth opening again these people do not keep a good hygiene and then they do not have good nutrition all these are again independent positive factors for the development of malignancy now once we see the religion after inspection then we just look for margins if they're available for a therapeutic resection we also palpate the tongue and to understand and to note the depth of infiltration clinically then we also try to see the submucous plane what happens is what we see is something like the tip of the iceberg sometimes this growth can grow beneath the submucosa and we can go into deep into the tongue musculature uh which has to be evaluated especially when the patient is away the next part of the evaluation is basically on the neck nodes we do need to know how many neck nodes are enlarged because of the malignancy on the ipsilateral side and also on the control letter size any uh node enlargement in the contralateral side is of a very sinister uh significance and that suggests that the uh the malignancy is a little more aggressive so as far as investigation is concerned a biopsy is must so biopsy is a method wherein you take a small piece of tissue from the lesion and we submit it through histopathological examination so by a biopsy can be taken with a punch biopsy forceps it's usually available in most of the surgical uh centers in the opd of general physicians you people i have seen most of the people tend to take with the help of aldi's forceps or sometimes with any other instrument sometimes with the knife also after giving local analysis so these are all methods of taking a biopsy they have got their flaws and all that but if you've got a biopsy forceps now especially a small punch biopsy forceps it's easy it does not even require a local anesthesia and it can be taken as opt it does not cause much bleeding and it is safe and with the punch biopsy forceps usually a pathologist requires at least a minimum of two to three days to give a histopathology report once you get the histopathology report and once you know and confirm that it is malignancy then you do the following for the investigations so depending on the further investigations if you feel uh the region is in stage one two or sometimes even in stage three you can get away by doing only a chest extreme but in places where you feel it would be metastatic or something then it just see this can should be done to see for any metastases in the lung also more so if the patient is a bdd and cigarette smoker also so it is quite possible that this person has an incidental lung cancer and you must also look for this lung cancer by doing a chest x-ray these patients also may be having other cancers of the other oral quality or other parts of the herodized attract that is into the oral pharynx into the larynx post required of the platform fosa and also in the esophagus so generally when we look at a patient with c a term we also keep in mind that this person might be having an a second tumor elsewhere in the upper airway digestive tract now it is very debatable whether we need to investigate all of them because for all these investigations you need to do a bronchoscopy esophagoscopy then scans and all that and which becomes unnecessarily costly for the patient so most of the time we haven't noticed that this is not very cost effective so we don't really investigate them thoroughly with all these invasive and costly procedures unless we have a suspicious symptom suggesting of another magnet early lesions you don't really require to do a lot of local imaging but in cases which are advanced to know the depth of the infiltration to know if other muscles are involved in such cases it is better to do a ct scan or a mri to know how far the tumor is invading so that you can spare the uh and plan the surgical treatment little better now there these are different kinds of pictures you can see people come in different uh with different uh lesions and as you all know that cancer doesn't come in a set kind of or a customer uh disease so it is it depends it changes from different player person to person depending on his eating habits chewing habits his uh his habitus the way he keeps his hygiene so all these factors are important and then there are people who come very early with very small superficial legions but then some of these people keep on coming with quite large advanced decisions but to move so such happy people coming with that the advanced legions also so this is another set of pictures again you can as you can see so they come at a this [Music] various sizes as you all know legion he can palpate the legion by himself with his finger and if there is something is some change he should be able to report to a doctor unfortunately many of the poor people they don't have the you know attitude to go to doctors in early stages and sometimes the general practitioner or the local doctor tends to treat these patients as author saucers or small benign diseases and then they meant give him some treatment for about one or two months and by then which the lesion advances so this is one of the common reason why diseases come in little late stages in our country so i think if the general practitioners and all that become more and more aware so the lesions will be trapped very early and we can be will be able to give more cures so for that we need we need to keep on interacting with the dentists and the general practitioners who usually get these patients first and i can uh staunchly watch that in in my region most of we have got a very good network of head and neck cancer surgeons and a lot of them try to get diagnosed patients early and send them to us with the very early stages now again if coming to a point question so i want to know like what is the most common method of treatment of tongue cancer in your region or in your experience oh so we have 64 percent vote for surgery and 20 for keyboard yes okay so basically uh as you all can understand is a very important organ and it's a very functional organ so basically uh nobody would want to lose a part of the term unlike the breast unlike the the things which are not very physiologically active in many many organs which are not very physically active tongue is a very important part of the psych of a human being and nobody wants to lose the term but then the most important and the most popular and the most easiest way to cure tongue cancer is surgery followed by radiation therapy so the most common treatment is surgery wherein with surgery you remove the mass and radiation therapy is another dis where you radiate the lesion chemotherapy by itself is not a kirito modality for tongue cancer however chemotherapy is used in adjuvant with radiation therapy to improve on the cures given by radiation therapy sometimes chemotherapy is also used before surgery to shrink the tumor size so that surgery is done easily and the magnitude of surgery can be reduced to some extent so the principles of surgery so basically as you all know the principles of cancer surgery is that you have to do a wide excision why decision is now a very uh broad term so a wide oxygen in a thigh means that you can get you should achieve a wide skin margin of about 5 centimeters but in tongue you don't have so many so much tissues and every millimeter of tongue is very precious so the research has shown that most margins of 0.5 to 1 centimeter margin of the tongue uh palpable from the palpable edge is more than enough so this margin has to be three dimensional it should not be just on the superficial edge it should be from the depth also you have to have a 0.5 to one centimeter restricted margin so that is why the depth of infiltration is important and the surgeon should have a good uh what do you say judgment of the depth of the lesion so he he should he should look it as a three-dimensional disease and he should try to resect the death the deeper part of the disease with a good amount of margin when you do this then you lead to a defect in the tongue so if it's a small defect probably you may not need to do anything it will just heal by itself and the dysfunction caused by the defect is minimal however in most instances when a part of the tongue is lost there is going to be a big amount of defect and that defect leads to a small amount of cavity in the oral cavity now this what happens is when a patient start eating or when it starts trying to choose something with uh up with the with after a hemiglass section what happens is that there is a because of a defect the food goes and lodges there and then the food is not ab he is not able to push the food into the uh between the jaws so thus what it keeps on stagnating there then every time while eating food he has to keep on clearing his mouth with the help of a finger so we need to put in some amount of some kind of processes there so to prevent the lodging of the food so that is why the intent of that is the basic intent of doing reconstruction in this tongue cancer and basically in all organic cancers especially because wool cavity as you know is very very precious because most of the functions are very important and they are part of daily life so every part of the oral cavity most of the time it requires the uh some amount of reconstruction and in order cavities see the more the most of the lesions come about even if they come early they are usually at least one to two centimeter in size and if you take one on one centimeter on either side you end up taking about three to four centimeters of lesion which is quite a big i mean a big amount of defect and that defect should be reconstructed otherwise again what happens is that there is a tendency to cause scarring stricture formation and limit the mobility of the tongue and limit the mobility to the oral cavity and prevent the proper function so there you can see in this picture that a good amount of margin is being taken a margin is pretty easy preliminarily marked with the help of a quarterly what we usually do and then the restriction occurs so this is another case wherein the tongue is pulled out of the wool cavity under anesthesia and then we go on doing the resection [Music] this is a case of a right hemiglossectomy as you can see we are holding holding the tongue with the helps of a corset on the right side and the lesion is being divided with the help of a tree we usually try to uh use a quadriford division and not any sharp instrument like the blade or the scissor because uh the tongue is a highly vascular organ and it keeps on bleeding and if you try to do a surgery in a breeding field you may tend to lose your margins and you may tend to go closer to the disease and make your surgery ineffective or lead to a recurrence very soon later on so this is these are the pictures of again how the tongues are resected and that's the resected specimens so there you can see the resected specimen now once you remove the specimen what we usually do is we label the margins though most of the time it's on the lateral border and the pathologist can orient it without even er enabling even if you just do the side of the uh this is it's more than enough for the pathologist but still we try to visually label it at least by two markers either the anterior or the superior markers which is most commonly labeled our label choices of labeling now coming to the reconstruction basically i would uh one of my important point which i wanted to stress uh to you people is that you must know about reconstruction of the whole cavity especially the tongue now see we cannot use some of the functions of the tongue because the tongue is a highly muscular highly active highly innervated structure and a lot of spatial senses are also there in the tongue but some the basic intention of reconstruction is not to get all the functions of the tongue back but as i told you that basically we want to put some kind of tissue over there some kind of processes and this is not for the looks it is for that it gives something it acts as a filler so once it acts as a filler the rest of the tongue can uh use this filler to help move the food particles in between the jaws or to help in duplication and to help in swallowing and to prevent the rest of the tongue being scarred or being like contact with no reason so this is a popular flap it is called the free radial forearm flap wherein we take the skin from the forearm that is or from over the wrist so it is based on mostly the radial artery and the uh when accommodates or a separate vein around there so we take this flap and we do something what we call it a micro vascular reconstruction so the artery and the vein are taken along with the tissues intact and this whole segment or this whole segment is implanted and uh into the oral cavity over the defect and the vessels are anesthetized with through some of the vessels in the neck mostly the facial artery or the superior thyroid artery and the vein can be honest most is one of the veins in the neck or sometimes to the internal jugular vein so this is how the you can see that skin is being sutured to the tongue into the oral cavity and this is the defect on the forearm so for this forearm defect what we tend to do is we try to put in a split thickness graft and cover this defect and uh so this will heal by second uh uh primary intention we have to be careful because that for uh the hand has got two vessels in the radial artery but um one artery is more than enough for the maintenance of the vascular supply of the hand but then sometimes there are some patients where in the arcade may not be continuous and these people can have a block in the [Music] vessels if you just resect without doing the allens test so ln stress is a simple clinical test uh wherein you just check the radial artery and the lr flow over there and then you go in for uh surgical uh before you do the surgical procedure so there again you can see another patient with the uh in the post-op period where we have implanted the free radial forearm plant so in this picture you can see how the micro vascular anaesthetist is done so the radial artery is anaesmos to the facial artery and the vein is another most to a neighboring vein so veins in the neck can be uh numerous but then you have to spare them selectively with a lot of care so that there will be good recipients to the donor vessels so we usually use eight zero nine zero ten zero uh proline to do the suturing and uh though it can be done under loop sometimes you may need the help of operating microscopes so uh there you can see other another picture of the how the micro vascular anastomosis is done within the vessels are anesthetized to each other so micro vascular anastomosis is a special skill it requires a lot of dedication most of the plastic surgeons nowadays can do it and uh the skill most of the plasticine all over the country are now able to do this microscope procedures thoroughly and with a lot of success so this is this particular procedure has become very common in the last decade the ticket before that it was a little uncommon and when i was uh doing my studies and all that it was very very we hardly saw any microsd reconstructions but today in most centers all over the country microscopic conditions are being done so these are the end result of this uh free radial foram flap so there you can see the tongue being replaced and a new tongue being formed in the oral cavity so these are some more pictures where you can see the tongue the half of the tongue is skin and half of the tongue is mucus and these people invariably will be having good amount of uh function of the time so in the post of care basically if we have done a flap we have to do a flap monitoring otherwise it's all about value feeding in the post-op period antibiotics hygiene won't care and then flap monitoring is a little tedious process wherein the nurses and the resident doctors have to keep on observing the flap repeatedly to see sometimes for any failure that in in the sense that the flap can thrombose the frap can get blocked and sometimes it can be bleeds so in such a eventuality what we tend to do we can we may need to do a urgent re-exploration and salvage the flap again so if you are late in doing that then sometimes the flat undergoes death and necklaces if your skills are not so good then the micro and square anastomosis will not be good and then the flap may undergo either venous thrombosis or arterial thrombosis which may lead to the death of the flap and then you would end up with a lot more of a misery rather than real benefit when we wait for the histopathology of the the scene most of the time when we are operating on the tongue we also operate on the neck because it is unless the lesion is very very small small and superficial in tongue cancer there is a high indices of neck node positivity so we tend to do a kind of minimally at least [Music] selective node distraction that is the no distribution of the upper neck what we call technically as a level 1 2 and sometimes 3a or something like that so the staging has changed as far as tone cancer is concerned previously the tongue lesions were only staged depending on the size that is less than two centimeter two to four centimeters more than four centimeters but now a new dimension has been introduced that is the depth of the region so now uh depending on the type that staging also has also changes so you can see in on the left hand side when the t2 legions 5 to 10 millimeter more than 10 meter deep they are staged differently as far as the t stage is concerned the nodal staging more or less remains the same except for the fact that extraordinary extension if it is positive it ends up becoming in three dc so extraneous extension that is when the tumor is going breaking out of the node and going into the other tissues so that is very sinister and it's not a good finding and that indicates that it has a poor prognosis and it is staged as m3 the other nodal staging was as previously uh has been maintained as before so n1 is basically a node with less than three centimeter in size and into a is a three to six centimeter size single node into b is multiple ipsilateral nodes or multiple nodes on the same side and n2c is either contralateral nodes or bilateral nodes without any external nodal extension so these these are the basic parts of information we tend to get on the histopathology report now as far as metastasis is concerned just like in any cancer metas distant metastasis is one m1 and no matter is m0 so most of the time distributor stresses if it occurs is mainly in the lung sometimes it can occur in distant lymph nodes elsewhere in the body like in the axilla it can occur in the groin or sometimes there can be bone mats uh because squamous cell carcinoma has a particular liking for bones and the lung very rarely also in the liver so the group staging again we have got four groups that is stage one two three four and uh any t4 or into the three ends up in stage four which is common in oral cavity cancers now after surgery we all most of the time tend to give them additional radiation that is adjuvant radiation so these patients who require radiation is patients who have got a t2 to t3 disease or even in any uh depth lesion wherein the depth of infiltration is more than four millimeter which almost always occur is present in our patients again most of the patients are all already having some kind of nodal disease so any node positivity is a indication for radiation therapy now addition of chemotherapy to radiation therapy in the adjoined sitting is if and there is extra normal extension when there is t4 disease when the node status is little higher like something like uh n2 n3 dc's so in all these instances we tend to add chemotherapy to radiation to improve upon the results but however as you must also know the addition of chemotherapy to radiation will also increase the morbidity and it can lead to more problems and at least little more unpleasant than plane radiation therapy so radiation therapy previously uh about 10 years ago most of the centers in our country were basically cobalt units and used to give [Music] radiation with cobalt therapy but now in the last decade there is the influx and many setups have got the linear accelerators where we can give 3d crt imrt and sometimes even vmat or rapidar planning so these are different techniques of radiation therapy which have their own advantages and disadvantages and uh these are popularly used with the linear accelerator to give the external beam radiation therapy which is mostly used for oral cavity cancers brachytherapy is a kind of radiation therapy which is something like a local radiation therapy so it is given either mostly with the help of small tubes introduced in the engine in the lesion so it is used as a primary treatment wherein surgery for some reason cannot be done or is to be avoided so brachytherapy can be done by giving local radiation therapy it's it's a little confusing treatment which i do not want to elaborate right now in this talk in chemotherapy we got numerous drugs uh the most popular drug used in our country is cisplatin acute excellent carboplatin are also used then there are other drugs which are known to be effective uh a little less commonly used methotrexate mitomyci high fluorescein and sometimes nowadays we tend to use some kind of monoclonal antibodies we don't have much uh data on this but then in our occasional patients monoclonal antibodies can also be useful to especially in the palliative city a good amount this of these patients get cured but however there are some people some unfortunate people who tend to have recurrences the recurrences can be local local frequencies usually are because of uh if the primary disease is quite extensive or advanced or if your surgery is compromised so most of the time i don't think anybody will operate uh try to be very casual as far as treating is concerned so we don't usually get local recurrences especially if the tumor i mean the stages are low but then we tend to repeatedly get a lot of regional uh recurrences especially in the neck in the opposite neck sometimes in the lower neck and all that or in the skin of the neck so these all regional frequencies do keep on occurring and an unfortunate patient sometimes they do have also have distant metastases so so this is the pattern of reconsists uh a good amount of time cancer people get cured in when the patients come in stage one and stage two i can say that at least around 60 to 80 percent of these patients keep on getting cured but when patients come in stage three the cure rate falls to only about 30 to 40 percent and when the patient has come with metastasis though uh people say that there is about 10 percent fire survival in my personal opinion that hardly you get people uh with stage four who can survive for more than uh more than two years i mean with matters when they have metastasis so the causes of death in lung cancer mostly it's because of advanced disease and uh the disease could be uh [Music] lead to eroding of many many of these vessels in the oral cavity or in the neck and sometimes it can be due to lung metastasis it can be due to metastases or lung masses compressing into the throat or into the trachea or in the larynx sometimes because of the oral cavity cancer these patients keep on having poor nutrition they lose weight they don't take good intake they'll become malnourished they become and then they lose their life many of these patients because of disease because of the surgery they tend to have a poor uh respiratory function they can have respiratory failure due to metastasis or due to chronic aspiration or sometimes acute respiration they tend to keep on having lung infections and they tend to die because of respiratory failures these patients are also prone to have infections in the local that is either into the oral cavity or into the neck and they can keep on getting some abscesses in their region which can wherein they can go in for sepsis and they lose their life so these are the common causes of death as far as tongue cancer is concerned and i think that would be my last slide because i'm uh tongue cancer is a very very vast topic if i keep on talking there is no end for it so thank you i have kept two flowers because you know all the old cavity cancers are little unpleasant to look at and so basically at the end of the day i want you people to have look at something pleasant so thank you all for very patient listening thank you so much so we have quite a lot of questions so looks like yes because one one one disease which people are very emotional very and which is quite common this is in many parts of the country yes so very true we had a question from dr vikka's like um the sharp tooth leading to love okay sharp tooth leading to lung cancer yes sir he had a question and also there was one more question from dr vikas that there's a dilemma in patience like if they get uh ulcers they're like scared so how to go about it how to make them comfortable see a sharp tooth leading to not lung cancer the lingual cancer i mean the tongue yeah basically so sharp tooth can impinge on the soft tissues of either the tongue on the inner side or into the buccal mucosa on the outer side so what happens it keeps on getting injured and with every injury there is a repair mechanism going on the cell death cell repairs regenerations multiple regenerations so one of these cells undergoes some kind of mitosis is some kind of genetic imbalance and uh that leads to the development of a abnormal cell which is not in the control of the human body and it develops into pregnancy so this is basically the tumorogenesis what we say uh as far as the cancers of the concern so this is how the process occurs right so uh as for son he has got cancer right immediately when you see a tongue answer but then every tungle sir you have to be suspicious because you see it's a curative disease and you do not want to lose a patient so see nowadays patients are also quite aware so once you see a tongue answer all you have to do is at least palpate the lesion and if you feel some kind of induration or hardness in the lesion then you immediately refer to a onco surgeon if he is available in the near vicinity if not referring him to a uh oral surgeon or a general surgeon or an ent surgeon should be quite enough who can take a decision for whether to biopsy it or to proceed further this advice is for the general practitioners but then the surgeons or the individuals can take a biopsy by themselves there right so so uh we have a question from dr richard so how effective are x-rays on diagnosing sea of soft tissue entity like tongue x-rays are not very useful definitely exercise and in a i mean basically you can virtually inspect everything so when you can inspect everything i don't think you should do any kind of uh you could you should not spend a lot of effort on because though i just spoke about ct scan and mri but your primary this thing should be the ability to inspect them okay so so we have a question from dr swathi what would be the most common side to check the metastasis uh like in the other sides too uh [Music] swati what happens is that most of the time the neck node mattresses are the most common especially in the upper part of the neck however there can be some skip metastasis in the lower part of the neck so a thorough examination of the neck is imperative and especially clinically as we are always taught that the surgeon or the physician who should go behind the patient to palpate the lymphoids of the neck this is a very important clinical step where in you can detect most of the lymph nodes and your palpation is a very good method because even small small nodules like about three to four millimeter nodules can be filled with palpation instead of doing a lot of university investigations like sonography cds can mri the as far as metastasis is concerned most of these cancers if they have when they metastasize metastases mainly to the lung but then most of the time it's also always a second primary rather than a metastasis especially in oral cancers because it's a little uncommon for the the initial uh setting itself to have the uh patient of oral cancer to present with the lung metastasis so uh i so we don't break our head in doing a lot of injuries as far as medicine is concerned routinely we limit ourselves to just stay either it's just x-ray or sometimes at the max is chemical just right so so we have a question from dr nikki like which is the best medication to relieve the pain of the ca tongue patient oh okay you see yeah that is very nice question [Music] a lot of discussion be uh occurring in our country uh of late uh basically most of the patients when they go into advanced cases they have intolerable pain so pain management in oncology is a very important part of our practice and sometimes we are not able to cure the patient at least we need to comfort the patients and we need to give him adequate amount of anaesthesia to relieve him of his pain and let him give his rest of his life at least happily unfortunately what happened was uh there are a lot of laws in our country which we are preventing us from using some weird drugs so basically most of the time we used to limit our painkillers to only nsaid and to some uh uh synthetic opioids of the biosemisynthetic opioids like maximum what we should do was like codeine or trim at all and we'll use to limit to that but nowadays i mean the uh of late i think about one month ago and all that then the noise being lived well is little more and drugs like buprenorphine fentanyl i mean morphine are more easily available so morphine is tablets are being available now all over the country little more easily and the production is also being increased in our country so morphine is a very good drug in the late stages to uh relieve pain especially in the advanced cancers in that time [Music] till that time we what we can do is we can do in the initial series limit ourselves to nsaid and try all those things [Music] right so so we have a question from dr akash like if the legion is a smaller one can regeneration activity take place definitely see basically you see cancer is one such such a bad disease that even when it comes in sizes of one millimeter or two millimeters so it is it is going to be a dangerous in uh and there is one such disease which [Music] [Music] unless so to prevent the killing the cancer therapy has to be perfect so [Music] any effective therapy any uh improper therapy on any uh or if therapy is not given properly or any uh non-specific prefigure cancer is not going to die so cancer requiring a lot of aggressive and a very proper scientific therapy to get good results so we have a question from dr nikita is there any possibility of making prosthetics oral prosthesis for tongue cancer yeah actually it will be correct because see becoming a very active uh or a very agile structure keeps on moving it is difficult to retain the processes so it is it will be a little uncomfortable also to have a process is there yes all right so oh so doctor dr dr nellor dr kunal everyone's saying very informative session so thank you so much oh thank you thank you guys yes sir oh so our doctor zahid is asking a question like after the surgery like there's a little uh problem while speaking are in the tastes so how to go about it like it's all dirt see depends on the magnitude of the surgery yeah if the surgery is quite large and all that then the patients have a little eddy mass swelling wherein the patient's a little bit uncomfortable and if the patients undergo radiation therapy they might lose their taste to some extent but then today's radiation therapy is also very very good the accuracy of the radiation therapy is more focused so most of you don't really radiate the rest of the oral cavity and you preserve the test uh function with significant effect and to that effect we also tend to preserve the salivation to sing significantly so people patients tend to eat their food well and taste well and maintain their salivation also include with modern techniques of radiation therapy please elaborate on brachiotherapy brachytherapy is local therapy there are different kinds of brachytherapy so there can be some uh like whether it's on the some surface lesions or know that you can keep some uh tubes and all that on the surface of this small amount of time and come back again and remove the beads so this basic technology means the break e3 is a therapy which is from nearby so actual game beam comes from a distance like the light rays it comes from a distant uh tube or a distant machine while in breaking therapy the iridium source goes near the tumor and launches and uses radiation vacation invariably tends to give a lot of high dose of radiation therapy so that is why this local therapies tend to be very effective and at the same time they break the rays of the bricky therapy don't travel too far so thus it is not able to irradiate distant part of the body but when it is localized radiation three that one by giving local treatment only in one or two settings so it is definitely has an advantage that you can avoid surgery in some instances and it's more more easy to do but generally uh brachytherapy is looks more uh nice on the paper practically we have always noticed that surgery is easier to do has got good results and technically uh the surgical procedure is easily done by many people compared to brachytherapy variant you have to have a lot of complexities in treatment and then the results are not as good as surgery so there is a tendency for patients to be subjected to surgery compared to cracking therapy right so so we have a question from dr saudav uh so there's an ulcer of a patient with hepatitis b from last three years so how do we treat it so this could be a benign answer also so this especially with lot of uh male compositions with a lot of uh multiple uh other diseases diseases tend to have a lot of active sensors tend to have a lot of horizon or something of that fungal infections from lesions so it's common in patients with multiple disorders and diseases that have oral lesions also so this helped in fact i can't uh really put a lot of uh information right now unless we see the case and have a proper discussion of the patient yes sir so we have a question from dr kailash like what are the early signs and symptoms do we see in when the patient comes to the clinic well basically the profile of the patient most of these patients are laborers or their poor farmers or poor shopkeepers or something of that sort so they are generally from the low for socioeconomic state and these patients only come when the lesion really causes symptoms initially the lesion though it is noticed by these people they just ignore it they tend to see that there is a harmless lesion occurring in the ovaries they don't really bother but then when it starts growing then it may tend to bleed especially during eating during rushing or when by even by touching and it starts bleeding then they get a little worried and then they come together and then if some of their friends or one of other ways they suggest that it could be oral cancer and then they come running to the doctors but most of the time it's to begin with it does not have much symptoms excessive salivation can be a symptom bleeding it is usually not painful in the early stages only when it progresses to involve the nerve or the bone only then it becomes painful so in the initial stages it is a little painless that is why these people tend to ignore unless it is very large it doesn't really cause any problem while it's mastication and deglutation is concerned and these are relatively rare cases that people tend to wait till the tumor becomes large and then the comforts of meditation therapy i mean surgery right so so dr dan and does asking like are there any new surgical techniques being used nowadays um for can see a tongue see basically most of the surgical surgery we do into the ovary cavity is with the help of a cautery so that is watery is a uh instrument where in the use of electricity we produce uh thermal injury and that it is a specialized machine then it starts splitting the tissues and goes on cutting the tissues with minimal bleeding so this is a simple whole idea of behind the electroporter apart from electrocutery there are other instruments like uh people there is a harmonic kind of thing then you can go on dividing the tissues using use the help of ultrasonic emotion sometimes there are lasers wherein a laser can go on dividing the tissues with the help of light energy but then these are all having the disadvantages and still the most common instrument used all over the world property is the electrophore right so so we have one more question from dr kailash like what is the survival rate of in the patients with link carcinoma okay if they come in early stages like age one and two around sixty to eighty percent of these patients do survive five years and sometimes we have long term survivors like we have a lot of 20-year survivors also but when uh generally most of these patients tend to fall in the group of stage three wherein uh i either have enlarged nodes or whether a lot of deep infiltration these patients do not really do well and then then only about 30 to 40 percent of these patients do survey five years and then since you as you know that cancer is also a free kind of field cancerous that is eating tobacco and scary the substances of the carcinogenic agents are also affecting the lot of mucosa in the overall cavity so the rest of the uh because in the world it is also susceptible to develop marriages so apart from this cancer coming again these patients are susceptible to develop cancers in the other sides and when the patients come in stage three and all that the survival comes down and when it comes to stage four or especially when patients come with metastasis dystrophy so if a patient comes with dystrophy is unlikely to survive for more than one year a year or maximum too in my experience though theoretically we uh many textbooks keep on saying that that's 10 percent i hardly see anybody surrounding for more than five years once a patient is about this metastasis true so so we have a question from dr abba like uh electrocautery specification for the use of oral cavity which cautery sir do you recommend the powdery modes are coming uh two broad modes one is the cutting mode and the cognition the cutting has multiple again cutting features with the blend blend factors and all that and the coagulation has got different factors like the spray coagulation the plant coagulation so all this the use of equator is again personalized my country i like in india yeah i've seen most of the surgeons use kind of coagulation more to do the cutting because coagulation maintains trying to do a when you cut the tissues with the coagulation more so there's very less bleeding and you can do the surgery with very minimal bleeding but personally i want to use the cutting mode because cutting mode is very fast it goes on cutting and when you see a blood vessel where you can you you can be very skillful you can [Music] see you can shift coagulation more and you can cooperate it or sometimes the blood vessel is large you can ligate it and then proceed with the surgery so i personally use cutting mode because the surgery so um so can we take one or two questions more then there are bipolar modes those are not very popular by bipolar there is a kind of bipolar pottery so bipolar is popular as far as tone cancer is concerned unless you want to select youtube and calculate some blood vessels so dr ajay is asking like is mri helpful and like pre-operatively to see the legion extension well of course good mri i mean a good uh 1.5 tesla mri is good to identify and delineate the lesion especially in a muscular organ like the tongue so mri is good as you know for soft tissues and the tumor identification and it can help you reveal if there is any deep implantation if there are any skip metastasis i mean some local metastasis lesions where small nodules of the tumor apart from the primary tumor sitting elsewhere in the tongue which you could not identify on palpation so mri can be as far as understand the whole complexity of the time true so uh so we have question from dr swati like how do we determine that how much time elapses between the progression of one stage of cancer to the other stage okay so this is a very popular question asked by the patients so they keep on asking since when it is has occurred so this it is very difficult to say answer this question because malignancies are you know very unpredictable as far as their growth patterns are concerned generally it is believed that it takes about [Music] around six weeks for a tumor to uh be i mean visible then after another six weeks the tumor again doubles so basically what we call the doubling time it's around four to six weeks in oral cavity cancers so every four to six weeks keeps on doubling right so dr swati i hope this answers your question so i think we've almost covered all the questions [Music] thank you so much sir thank you so much for coming back and we are hoping to see you for the next sessions yeah yeah thank you so many and i think there are a lot of questions today yes [Music] uh chatting with all of you people it does great interacting with me yeah thank you thank you have a good evening thank you

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dr. Sharad Desai

Dr. Sharad Desai

Director, Mahatma Gandhi Cancer Hospital, Miraj

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dr. Sharad Desai

Dr. Sharad Desai

Director, Mahatma Gandhi Cancer Hospital, Mir...

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