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
- 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, 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.[1]
- 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. 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.[2]
- Partial glossectomy is commonly required for locoregionally advanced disease. 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.[3]
- 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.
- 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.
- 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.
Management of the neck
- Elective treatment of the neck in patients with stage I and II oral cavity cancer is not well established.[4]
- Most reports have found that increasing tumor thickness is associated with an increased risk of occult metastases and reduced overall survival.[5]
- Studies recommend a tumor thickness cutoff of 4 mm as a threshold for elective neck dissection.[6]
- The benefit was present in all subgroups, except for those with a primary tumor depth ≤3 mm.
- 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.
- Patients with primary tumors close to or involving the midline should be managed with bilateral neck dissection.[7]
- Sentinel lymph node biopsy may be an important option between observation and neck dissection in patients with intermediate-thickness tumors.[8]
- 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.
References
- ↑ 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.
- ↑ 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.
- ↑ Bessell A, Glenny AM, Furness S, Clarkson JE, Oliver R, Conway DI; et al. (2011). "Interventions for the treatment of oral and oropharyngeal cancers: surgical treatment". Cochrane Database Syst Rev (9): CD006205. doi:10.1002/14651858.CD006205.pub3. PMID 21901703.
- ↑ Huang SH, Hwang D, Lockwood G, Goldstein DP, O'Sullivan B (2009). "Predictive value of tumor thickness for cervical lymph-node involvement in squamous cell carcinoma of the oral cavity: a meta-analysis of reported studies". Cancer. 115 (7): 1489–97. doi:10.1002/cncr.24161. PMID 19197973.
- ↑ D'Cruz AK, Vaish R, Kapre N, Dandekar M, Gupta S, Hawaldar R; et al. (2015). "Elective versus Therapeutic Neck Dissection in Node-Negative Oral Cancer". N Engl J Med. 373 (6): 521–9. doi:10.1056/NEJMoa1506007. PMID 26027881.
- ↑ Schilling C, Stoeckli SJ, Haerle SK, Broglie MA, Huber GF, Sorensen JA; et al. (2015). "Sentinel European Node Trial (SENT): 3-year results of sentinel node biopsy in oral cancer". Eur J Cancer. 51 (18): 2777–84. doi:10.1016/j.ejca.2015.08.023. PMID 26597442.
- ↑ Pedersen NJ, Jensen DH, Hedbäck N, Frendø M, Kiss K, Lelkaitis G; et al. (2016). "Staging of early lymph node metastases with the sentinel lymph node technique and predictive factors in T1/T2 oral cavity cancer: A retrospective single-center study". Head Neck. 38 Suppl 1: E1033–40. doi:10.1002/hed.24153. PMID 26040238.