Tongue cancer surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Simrat Sarai, M.D. [2]

Overview

Surgery is the mainstay of treatment for tongue cancer.

Surgery

• For small tumors excision is possible with a hemiglossectory or partial hemiglossectomy. Reconstruction of the tongue depends on the size of the defect. When less than a third of the tongue has been resected primary closure is possible. Larger defects require pedicle or free-flap reconstruction. Larger lesions which cross the midline, although sometimes technically resectable with a total glossectomy, are usually not resected due to the operation being poorly tolerated. In tumors that extend laterally across the floor of mouth and into the mandible, resection is challenging often requiring segmental mandibulaectomy and reconstruction.
• Partial glossectomy is commonly required for locoregionally advanced disease.
• Occasionally, total glossectomy is required in cases where bilateral lingual arteries are involved by cancer. In those cases, total laryngectomy may also be required to prevent aspiration. The addition of postoperative radiotherapy or chemoradiotherapy, appears to improve disease control compared with surgery alone.
• Primary treatment with sequential therapy or concurrent chemoradiotherapy may be preferred when total glossectomy and laryngectomy are indicated, given the overall poor prognosis and functional loss associated with surgery.
• Surgery is generally recommended for oral tongue cancer, if good functional rehabilitation can be achieved with reconstruction
• A partial glossectomy with negative margins can preserve speech and swallowing for most stage I and II lesions of the oral tongue. The choice of reconstruction and intensity of rehabilitation determine the ultimate functional outcome.
• Assessing surgical resection margins can be difficult. Deep tongue muscle margins are not found in a single plane, in contrast to the radial mucosal margins. In addition, striated tongue muscle fibers shred or fragment with tissue handling during and after surgery, leaving a less reliable surface to assess margin status. Therefore, close deep surgical margins should be interpreted with caution and more aggressive treatment may be indicated compared with close radial mucosal margins or close margins in other disease sites.
• With larger lesions and impaired tongue mobility, implying deep tongue infiltration or floor-of-mouth extension, a more radical approach is required. The tongue may be approached through a lateral pharyngotomy. If more exposure is necessary, a mandibulotomy may be required for access if the mandible is free of tumor. When the tumor involves or extends to the gingiva, consider resection of the mandible.
• The ideal surgical approach to oral tongue tumors depends on the tumor size and the involvement of adjacent structures. For most small T1 and T2 lesions confined to the tongue, peroral horizontal wedge excision with primary anterior-to-posterior closure may be achieved quite easily.
• Another strategy is to use the combination of a glossectomy and brachytherapy. In this setting, controlled margins of excision are obtained, followed by the use of brachytherapy needles prior to awakening from general anesthesia. The patient is then monitored postoperatively for 48 hours, during which the radiation oncologist proceeds with the brachytherapy dosimetry and implantation of radioactive seeds for periods of up to 72 hours. The needles are then removed and the patient's recovery proceeds in-hospital until the patient meets discharge goals.
• The management of the neck in patients with early stage cancers of the tongue is controversial. The risk of lymph node metastasis is proportional to depth of invasion. However, preoperative determination of depth of invasion is difficult without a full thickness biopsy, which is rarely done. Distinguishing between patients at low and high risk of lymph node metastasis is variable between surgeons. The decision regarding neck dissection requires a comprehensive assessment of the potential risks and benefits for each early stage oral tongue cancer patient. Patients may have “skip metastases” with involvement of level III or IV without involvement of levels I and II. Thus, a selective neck dissection of levels I to IV may be more appropriate than a supraomohyoid dissection of levels I to III.

MANAGEMENT OF THE NECK 

Elective treatment of the neck in patients with clinically N0 stage I and II oral cavity cancer was historically controversial [54]

but its value for appropriately selected patient subsets has now been established in a large randomized trial [55].

Tumor thickness is a useful parameter for predicting occult metastases in squamous cell carcinoma of the oral cavity, particularly for tumors arising in the oral tongue. Although the definition and measurement of tumor thickness or depth of invasion have varied between studies, most reports have found that increasing tumor thickness is associated with an increased risk of occult metastases and reduced recurrence-free and overall survival [56,57]. 

Improved imaging techniques, including functional or molecular-based studies prior to surgery, may eventually prove useful in selecting patients for neck dissection. Sentinel lymph node biopsy is an emerging technique that may eventually be an important "middle of the road" option between observation and neck dissection in patients with intermediate-thickness tumors [11,12]. 

Noninvasive techniques to assess tumor thickness (clinical palpation, computed tomography [CT], positron emission tomography [PET], magnetic resonance imaging [MRI], intraoral ultrasonography) and representative biopsy or frozen section analysis each have limitations. Thus, the thickness of the primary tumor is often unknown prior to surgery. As a consequence, many head and neck surgeons either decide empirically before surgery based on clinical features or defer elective neck dissection pending final histopathologic examination. 

studies led many to recommend a tumor thickness cutoff of 4 mm as a threshold for elective neck dissection, we now recommend ipsilateral selective neck dissection (levels I to III/IV) to reduce the chance of regional recurrences for cancers with more than 3 mm of invasion in patients with an oral tongue primary. [55] 

patients were secondarily randomized to be followed by physical examination only or by ultrasound (but not CT or PET). 

The initial analysis of this trial was based upon the first 500 patients enrolled, as prespecified by the data and safety monitoring committee. There were 427 primary tongue tumors, 68 arising in the buccal mucosa and 5 in the floor of the mouth; the trial included 221 patients with T1 tumors and 279 T2 tumors. 

Following excision of the primary tumor, patients assigned to an elective lymph node dissection underwent an ipsilateral selective neck dissection that included clearance of level I, II, and III lymph nodes. If disease was detected during the elective node dissection, surgery was extended to include level IV and V nodes. Patients assigned to a therapeutic neck dissection underwent a modified neck dissection (levels I to V) if a nodal relapse was detected. 

At a median follow-up of 39 months, there were 146 recurrences and 79 deaths in patients assigned to initial observation followed by therapeutic node dissection, and there were 81 recurrences and 50 deaths in the group assigned to elective node dissection. The benefit was present in all subgroups, except for those with a primary tumor depth ≤3 mm. 

Overall survival, the primary endpoint of the trial, was significantly improved in those assigned to elective node dissection (three-year overall survival rate 80 versus 67.5 percent, hazard ratio [HR] 0.64, 95% CI 0.45-0.92). Similarly, the disease-free survival rate was also significantly improved (three-year rate 69.5 versus 45.9 percent, HR 0.44, 95% CI 0.34-0.58). On subset analysis, the benefit was limited to patients with tumor depth >3 mm, although the number of such patients was limited. 

The primary site was the tongue in 85 percent of patients, and it is not clear whether neck dissection would have a similar benefit in patients with tumors arising elsewhere in the oral cavity. In addition, whether results might differ if eligibility was limited to patients with a negative neck on baseline CT or PET, or with more intensive follow-up imaging (CT or PET) for patients treated without a neck dissection is unclear. 

The optimal extent of neck dissection remains uncertain.  

A supraomohyoid neck dissection (levels I to III plus IV, although for subsites other than oral tongue, levels I to III) is typically sufficient for clinically N0 oral cavity cancer since level IV and V lymph nodes are rarely involved without clinical disease at other levels (figure 2) [40,58-60].  

For patients with oral cavity cancer, we generally recommend an ipsilateral selective neck dissection, levels I to III/IV, for stage I cancers with greater than 3 mm of invasion and for most stage II disease, except minimally invasive primary tumors. Levels IIB and IV are dissected at the discretion of the surgeon. Level V dissection is usually unnecessary. Patients with primary tumors close to or involving the midline should be managed with bilateral neck dissection.

Sentinel lymph node biopsy may be a viable alternative to neck dissection for select patients with early stage oral cavity cancer. Sentinel lymph node biopsy has been demonstrated to be safe and feasible in a multi-institutional setting [61,62]. Specialized training is required for the procedure, and there is a fairly steep learning curve. Sentinel lymph node biopsy has been more widely adopted in Europe than in the United States for early stage oral cavity cancer. The largest multi-institutional series from Europe included 415 patients and found a negative predictive value of 95 percent with the procedure [13]. 

To date, there remains no level 1 evidence comparing sentinel lymph node biopsy to elective neck dissection for early stage oral cavity cancer.

the technique may be most applicable to patients with primary tumors less than 3 mm in depth that have an intermediate risk of lymph node metastasis, and/or larger primary tumors that approach the midline. When performed, a negative sentinel node biopsy may replace planned neck dissection.

More specific recommendations incorporating the primary tumor site include the following: 

Elective neck treatment is usually not performed for T1 lower lip cancers. For T2 and larger cancers, elective dissection can be limited to levels IA and 1B (suprahyoid dissection) since lower lip cancers usually do not metastasize to lower cervical nodes without first invading facial, submental, and submandibular lymph nodes [63]. 

For all T1 and T2 oral tongue cancers with >3 mm depth of invasion, we suggest an elective unilateral lymph node dissection [64-67], including levels I to IV. Select oral tongue cancers may be appropriate for staging via sentinel lymph node biopsy. Sentinel node biopsy is experimental but, when negative, may replace planned neck dissection and may also be used to assess the contralateral neck for thicker tumors that approach the midline. 

For all lower alveolar ridge and retromolar trigone cancers, regardless of size, we suggest elective neck dissection, including levels I to III, given the particularly high incidence of occult nodal metastases [42]. 

For early stage cancers of the upper alveolar ridge and hard palate, the incidence of occult cervical lymph node metastases is low; therefore, elective treatment of the neck is usually not indicated.  

For buccal mucosa cancers, the facial lymph nodes adjacent to the facial artery and vein at the mandibular ramus are at high risk of metastasis, and particular attention should be paid to this area during an elective neck dissection. 

For patients whose primary treatment is radiation therapy, elective irradiation of the neck follows the same indications as for elective neck dissection, with attention to the same levels.