Tongue cancer surgery
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Tongue cancer surgery On the Web |
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American Roentgen Ray Society Images of Tongue cancer surgery |
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 tumours 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.[1]
- 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[2][3]
- 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[4] . Thus, a selective neck dissection of levels I to IV may be more appropriate than a supraomohyoid dissection of levels I to III.
References
- ↑ Fein DA, Mendenhall WM, Parsons JT, McCarty PJ, Stringer SP, Million RR; et al. (1994). "Carcinoma of the oral tongue: a comparison of results and complications of treatment with radiotherapy and/or surgery". Head Neck. 16 (4): 358–65. PMID 8056581.
- ↑ Fujita M, Hirokawa Y, Kashiwado K, Akagi Y, Kashimoto K, Kiriu H; et al. (1996). "An analysis of mandibular bone complications in radiotherapy for T1 and T2 carcinoma of the oral tongue". Int J Radiat Oncol Biol Phys. 34 (2): 333–9. PMID 8567334.
- ↑ Matsuura K, Hirokawa Y, Fujita M, Akagi Y, Ito K (1998). "Treatment results of stage I and II oral tongue cancer with interstitial brachytherapy: maximum tumor thickness is prognostic of nodal metastasis". Int J Radiat Oncol Biol Phys. 40 (3): 535–9. PMID 9486601.
- ↑ Byers RM, Weber RS, Andrews T, McGill D, Kare R, Wolf P (1997). "Frequency and therapeutic implications of "skip metastases" in the neck from squamous carcinoma of the oral tongue". Head Neck. 19 (1): 14–9. PMID 9030939.