You are in: eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > HEAD AND NECK ONCOLOGY Malignant Tumors of the Mobile TongueArticle Last Updated: May 4, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Benoit J Gosselin, MD, FRCSC, Associate Professor of Surgery, Dartmouth Medical School; Director, Comprehensive Head and Neck Oncology Program, Norris Cotton Cancer Center; Staff Otolaryngologist, Division of Otolaryngology-Head and Neck Surgery, Dartmouth-Hitchcock Medical Center Benoit J Gosselin is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society, American Medical Association, American Rhinologic Society, Canadian Medical Association, Canadian Society of Otolaryngology-Head & Neck Surgery, College of Physicians and Surgeons of Ontario, New Hampshire Medical Society, North American Skull Base Society, and Ontario Medical Association Editors: William M Lydiatt, MD, Professor and Division Director, Head and Neck Surgical Oncology, Department of Otolaryngology-Head and Neck Surgery, University of Nebraska Medical Center; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Karen Hall Calhoun, MD, William E Davis Professor and Chair, Department of Otolaryngology-Head and Neck Surgery, University of Missouri; Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders; Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine Author and Editor Disclosure Synonyms and related keywords: tongue cancer, squamous cell cancer of the tongue, malignancy of the tongue, leukoplakia, oral cancer, tongue malignancy, cancer of the tongue, tongue mass, tongue tumor, tongue lesion, oral cavity cancer, tobacco complications, tobacco use, alcohol consumption, Plummer-Vinson syndrome, quid, betel nut, slacked lime, human papillomavirus, HPV, human papilloma virus, iron deficiency, riboflavin deficiency, SCC, squamous cell cancer, tongue carcinoma, oral carcinoma, mouth carcinoma, erythroplakia, leukoplakic lesion, leukoplakia erosiva, erythroleukoplakia, nodular leukoplakia, infiltrative SCC, ulcerative SCC, infiltrative squamous cell cancer, ulcerative squamous cell cancer INTRODUCTIONSection 2 of 11
  Malignancies of the tongue represent one of the greatest management challenges for the head and neck oncologist because of the adverse effects of treatment on oral and pharyngeal function, the eventual quality of life, and the poor prognosis of advanced disease. The unique behavior of these tumors also requires aggressive management to minimize the risk of locoregional spread. FrequencyThe tongue is the most common intraoral site of cancer in most countries. The worldwide incidence of oral cancer varies widely. Because of this variability, cancer of the tongue is a serious public health problem with significant mortality and morbidity. Cancers of the oral cavity represent 2% of all cancers diagnosed annually in the United States. The disease affects males more frequently than females, with a male-to-female ratio of 2:1. In Europe and Australia, the incidence of oral cavity cancer is very low, accounting for less than 5% of all cancers. In France (male incidence rates up to 8 per 100,000 per annum), it is the third most common cancer in males and the second most common cause of death from cancer. In India, the incidence rate approaches 50% (male incidence rates up to 6.5 per 100,000 per annum). This incidence variability may relate to different societal habits, such as chewing betel nuts and habitual reverse smoking observed in Asia and the higher incidence of smoking and alcohol intake in certain European countries. EtiologyTobacco Of all potential etiologic factors, cancer of the tongue is correlated the closest with the use of tobacco products. Numerous studies have shown that up to 90% of patients with oral cavity cancers use tobacco products and that the relative risk of such cancers increases with the amount smoked and the duration of the habit. The incidence of oral cavity cancers in persons who smoke is approximately 6 times that of those who do not smoke. Exposure to tobacco causes progressive sequential histological changes to the oral mucosa. Over a prolonged period of exposure, these changes eventually lead to neoplastic transformation. These changes may be reversible if tobacco exposure is discontinued. The recent increase in the incidence of oral cavity cancer in young adults is significant. The explosive use of snuff, or smokeless tobacco, in certain regions of the United States has lead to increased numbers of buccal mucosa, mandibular alveolus, and tongue cancers. Alcohol The correlation between alcohol consumption, particularly hard liquor, and oral cavity cancer is also significant, especially in patients taking more than 4 consumptions per day. Approximately 75% of patients who develop oral cavity cancers consume alcohol, and the disease occurs 6 times more often in persons who drink than in those who do not drink. The role of alcohol consumption in the development of tongue cancer appears to be independent of cigarette smoking. The use of alcohol has a synergistic rather than cumulative effect on the risk of carcinogenesis. The risk for a person who smokes tobacco and drinks alcohol is 15 times that of an individual with neither habit. Other factors A number of other factors have been associated with an increased incidence of tongue cancer. The use of betel nuts or quid and slaked lime is a habit practiced by as many as 220 million people in India and the continent of Asia. This mixture is highly irritating to the oral mucosa. Plummer-Vinson syndrome, which includes iron deficiency, has been associated with an increased risk of cancer of the oral cavity. Increasing amounts of data suggest that vitamins A and C, along with the carotenoids, may be protective against epithelial cancers. The detection of mutations in tumor suppressor genes has been reported in patients with cancers of the oral cavity. Nitrosamines constitute the most abundant carcinogens present in tobacco. These agents can damage DNA, leading to point mutations. These point mutations lead to deregulation of tumor suppressor genes, the best characterized being TP53, which is located on chromosome 17. Other oncogenes associated with oral squamous cell cancers include c-myc and erb-b1. The human papillomavirus, an epitheliotropic DNA virus, is another possible etiologic agent for carcinogenesis, transforming cells to a malignant phenotype. Human papillomavirus has been detected in various amounts in persons with oral dysplasia, leukoplakia, and malignancy. See also Human Papillomavirus. Riboflavin and iron deficiencies are known to produce dysplastic changes to the oral mucosa. This may partly explain its relationship to alcoholism, which may result in riboflavin deficiency and oral cancer. The role of occupational and environmental exposures in the development of cancer is an expanding field of study and may eventually be more important once the underlying molecular biology of cancer is better understood. PathophysiologyAs with other areas of the upper aerodigestive tract, more than 90% of oral cavity cancers are squamous cell carcinomas. Most of the other lesions are of minor salivary gland origin. Lymphomas, melanomas, and sarcomas rarely occur in the tongue. The following information, unless otherwise stated, is related to squamous cell carcinomas. Premalignant lesions Leukoplakia and erythroplakia are the lesions with the greatest potential for malignant transformation. The term leukoplakia is defined as a clinical white patch of the mucosa that cannot be characterized clinically or pathologically as any other disease. Leukoplakia is considered a premalignant condition from the chronic irritation of the mucous membranes, resulting in increased rates of epithelial and connective tissue proliferation. Onset of leukoplakia generally occurs after age 40 years, with the incidence peaking before age 50 years. It is 2-3 times more common in men than in women. The fate of leukoplakic lesions has been the subject of much controversy. The rates of malignant transformation range from less than 1% to as high as 17.5%, averaging 4.5-6%. In one of Banoczy's studies, a cohort of 670 patients was monitored for 3 years; of the patients, 7.5% had spread of leukoplakia in the oral cavity and 6% of the lesions became malignant. Leukoplakia erosiva (erythroleukoplakia) and nodular leukoplakia exhibited the highest rate of malignant transformation. Erythroplakia is defined as a red, velvety plaque that is found on the oral mucosa and cannot be ascribed to any other predetermined condition. No sex predilection is recognized, and it is rarely found on the tongue compared with other sites in the oral cavity. Mashberg has considered erythroplakia the earliest sign of asymptomatic cancer. Squamous cell carcinoma Squamous cell carcinoma is by far the most common malignancy of the tongue, typically having 3 gross morphologic growth patterns: exophytic, ulcerative, and infiltrative. The infiltrative and ulcerative types are observed most commonly on the tongue. Early carcinomas smaller than 1 cm may be detected only during a routine clinical examination. In the case of symptomatic tumors, the most common finding is an indurated, ulcerated area of the tongue. The induration may extend deep into the tongue musculature and root of the tongue. In many cases, regional lymphadenopathy may be present. Generally, a correlation is recognized between tumor size, nodal presence, metastasis, and eventual prognosis. The relationship between histological differentiation and clinical stage of the illness has been the subject of debate. Currently, the site and size of the primary tumor are well recognized as factors that are more important. ClinicalMalignancies of the tongue may grow to significant size before they cause symptoms. Approximately three fourths of the cancer occurs in the mobile tongue and is most often well differentiated. Because of the relative laxity of the tissue planes separating the intrinsic tongue musculature, the cancer may spread easily and become symptomatic only when its size interferes with movement. Squamous cell carcinoma of the tongue may arise in apparently normal epithelium, in areas of leukoplakia, or in an area of chronic glossitis. These lesions are usually larger than 2 cm at presentation, with the lateral border being the most common subsite of origin. At this point, the patient may develop speech and swallowing dysfunction. Pain occurs when the tumor involves the lingual nerve, and this pain may also be referred to the ear. Carcinomas of the tongue base are clinically silent until they deeply infiltrate the tongue musculature. They are usually less differentiated. Because of the difficulties with direct visualization, they may extend into the oral tongue or have clinical lymph metastases before the diagnosis is established. The evaluation of a patient with tongue cancer begins with a detailed history, specifically inquiring about tobacco and alcohol use, pain, weight loss, dysphagia and odynophagia, referred otalgia, hemoptysis, hoarseness, and articulation difficulties. During a complete head and neck examination, specific attention is directed at the site and size of the lesion and infiltrating characteristics; furthermore, the physician should perform a thorough bimanual examination of the tumor, the surrounding floor of mouth, and the submandibular triangles. Nodal adenopathy is carefully noted with the manual examination of the neck and is compared to imaging studies obtained as part of the evaluation. A dental evaluation is also performed, with attention to dental hygiene, dentition status, and integrity of the mandible. Patients with additional medical problems or those who will likely have complications should be referred for evaluation by an internist or an appropriate subspecialist. Because surgery is often part of the therapy of these lesions, an opinion from a medical internist may be obtained to aid in the perioperative treatment of the patient. RELEVANT ANATOMYSection 3 of 11
The oral tongue is the freely mobile portion of the tongue. It is bordered anteriorly by the lingual frenulum and posteriorly by the circumvallate papillae. The root is the undersurface of the tongue at its junction with the floor of the mouth. The junction of the tongue with the floor of the mouth forms a gutter, the gingivolingual sulcus, where food and liquids flow to the oropharynx. The oral tongue consists of 4 anatomic regions: the tip, the lateral borders, the dorsum, and the undersurface. Posterior to the circumvallate papillae, the base of the tongue is anatomically part of the oropharynx. It is covered by squamous epithelium composed of circumvallate, filiform, and fungiform papillae. The muscular portion of the tongue is composed of 3 paired intrinsic and 3 paired extrinsic muscle groups. The extrinsic muscles, made up of the genioglossus, hyoglossus, and styloglossus, alter the shape and position of the tongue. The trilaminar group of intrinsic muscles, which is composed of the inferior lingual, vertical, and transverse muscles, originates and inserts within the tongue substance. They are responsible for the changes in the shape of the tongue during speech, mastication, and swallowing. The lingual artery provides blood supply to the tongue. A branch of the external carotid artery, it arises at the level of the hyoid, where it travels forward to lie deep to the hyoglossus muscle. At this point, it divides into various branches to supply the ipsilateral tongue. Its only anastomosis is with its contralateral artery at the tongue tip. A plexus of veins follows the artery, and the main lingual vein drains into the internal jugular vein. The hypoglossal (cranial nerve XII) nerve runs anteriorly between the submandibular gland and the hyoglossus muscle. Nerve fibers are sent to the extrinsic muscles; then, the terminal branches plunge into the tongue substance to supply the intrinsic muscles. The lingual branch of the mandibular nerve (cranial nerve V3) provides the sensory nerve supply. Taste is provided by the chorda tympani, a branch of the facial nerve, traveling with the lingual nerve. Because of its different embryological origin, the glossopharyngeal (cranial nerve IX) nerve and the superior laryngeal nerve, which provide sensation, motor supply, and taste, supply the base of the tongue. An extensive submucosal lymphatic plexus provides lymphatic drainage to the tongue. All vessels ultimately drain into the deep jugular lymph nodes, between the levels of the digastric and omohyoid muscles. Various lymphatic collection channels originate near the tongue tip, pierce the mylohyoid, and drain into first echelon submental and submandibular lymph nodes. Lymph node channels from the tongue base pass through the pharyngeal wall laterally below the tonsil to reach the jugulodigastric nodes. Because the lymphatic plexus freely communicates across the midline, cancer of the tongue frequently metastasizes bilaterally. CONTRAINDICATIONSSection 4 of 11
Contraindications to surgery for tumors of the mobile tongue include patients who are unable to tolerate anesthesia for such a procedure because of medical illness. In certain cases, patients may not be suitable for surgery if the tumor is deemed unresectable on the basis of its extent. Surgery would also be contraindicated in a patient refusing a surgical procedure. Because of the difficulty in tolerating anesthesia, these patients would also not be suitable candidates for brachytherapy. In these cases, such patients should be considered for external beam radiation therapy. WORKUPSection 5 of 11
Lab Studies
Imaging Studies
Diagnostic Procedures
Histologic FindingsSquamous cell carcinoma is by far the most common epithelial malignancy of the tongue, and nonsquamous cell cancers comprise fewer than 3% of all lingual malignancies. Also, the 2 prominent variants of oral squamous cell carcinomas that may be present are referred to as verrucous carcinoma and sarcomatoid squamous cell carcinoma. Verrucous cell carcinomas have been described as a unique form of squamous cell carcinoma related to human papillomavirus infection. In its early phases, the tumor may be subclinical and asymptomatic as a verruciform growth phase that lasts several years. In other patients, the lesion may appear suddenly or as a slowly growing lesion that has a sudden and rapid growth phase. The macroscopic appearance of these lesions depends on the duration of the lesion, the amount of keratinization, and the changes in the adjoining mucosa. A fully developed lesion has the appearance of an exophytic bulky lesion that is gray to grayish-red and has a rough, shaggy, or papillomatous surface. Microscopically, these tumors are broadly based and invasive through papillary fronds. They are composed of highly differentiated squamous cells lacking frank cytologic criteria of malignancy with rare mitoses. The surface of the lesion is covered with compressed invaginating folds of keratin layers. Typically, a blunt pushing margin and astromalike inflammatory reaction are seen. Sarcomatoid carcinomas are also referred to as pseudosarcoma, pseudosarcomatous squamous cell carcinoma, pleomorphic carcinoma, metaplastic carcinoma, and the spindle variant of epidermoid carcinoma. The tumor manifests as a rapidly growing, polypoid, and bulky mass, often in a site exposed to prior irradiation. The histogenesis of these tumors is not clear. In general, because of their heterogeneous nature, microscopic interpretation of these tumors is highly subjective. In addition, sampling limitations are inherent to any fine structural analysis. Electron microscopy findings from these tumors are likely to be of value only if epithelial features are present within the spindle cells. Malignancies of salivary gland origin also may occur, with adenoid cystic carcinomas and mucoepidermoid carcinomas predominating in histological subtypes. Relative to the palate, minor salivary gland malignancies of the tongue are rare. Oral mucosal melanomas to the tongue are rare relative to other oral cavity sites such as the palate, alveolar gingivae, and lips. Virtually any malignancy can metastasize to the tongue. Statistically, carcinomas of the breast, lung, kidney, and adrenal gland are the most common. StagingThe staging of oral cavity cancers is accomplished using the 1998 TNM system developed conjointly by the American Joint Committee on Cancer (AJCC) and the International Union Against Cancer (IUCC).
TREATMENTSection 6 of 11
Medical therapyA number of generalities predominate as philosophic tenets of tongue malignancy management. The general beliefs are that superficial lesions are treated with single-modality therapy (eg, radiation or surgery) and that large lesions are treated with multiple modalities (eg, combined surgery and radiation). Additionally, cervical nodes are treated with either surgery or radiation therapy, and survival increases if microscopically positive nodes are present. The therapeutic decision must take into consideration the patient's age, lifestyle, and willingness to participate in the therapeutic regimen. The treatments have substantially different morbidities and may result in significant differences in quality of life. If possible, a younger patient is treated surgically to avoid radiation therapy because of the known late adverse effects of radiation. Additionally, premature use of radiation therapy eliminates this modality from future consideration if the disease recurs. In an older patient, either modality may be chosen if the lesion is superficial and small. Avoid using a modality that preserves greatest function but places the patient at a greater risk of local or regional recurrence. Radiation therapy Radiation therapy may be used as a single-modality treatment for small or superficial tongue lesions. The local control rates for T1 and T2 oral tongue cancers are similar for surgery and radiation therapy. However, radiation therapy has the advantage of preserving normal anatomy and tongue function. Three main techniques of radiation therapy administration may be used. External beam radiotherapy using a single ipsilateral portal or bilateral-opposed portals may be selected, depending on tumor size and location, nodal status, and the possible inclusion of interstitial implants. A second technique is brachytherapy, whereby the tumor is treated by implanting a series of hollow needles, through which radioactive seeds are injected during the length of the treatment. This may be used as a single modality or can be used following a partial glossectomy with controlled frozen sections. One of the advantages of this technique is the almost direct administration of the radiation to the tumor bed. Often, this technique is used after the tumor bed has been preliminarily treated with external beam radiotherapy. Brachytherapy may result in significant tongue edema, necessitating an elective tracheotomy. A third technique is orthovoltage radiotherapy. Most successful in cooperative patients with well-marginated and exophytic lesions, cone therapy is administered prior to external beam radiation therapy. An intraoral cone is placed against the tumor bed. Either orthovoltage or electrons may be given with equal control rates. In early or moderately advanced tumors (ie, T1, T2, early T3), postoperative radiation therapy is considered if adverse histological features are noted in the pathology specimen of the primary tumor or the specimen from elective neck dissection. For advanced lesions, combined treatment with surgery is advisable. Most patients initially undergo surgical resection; however, many patients have recently been treated with high-dose (therapeutic) preoperative radiation therapy with either external beam radiotherapy alone or external radiation therapy plus interstitial radiotherapy followed by surgical resection of the residual tumor. The latter technique results in a less-extensive tongue resection, hopefully without compromising the prognosis. Radiation therapy is considered a valid option for the primary management of small oral tongue cancers in patients who refuse surgery or those who are poor surgical candidates. Chemotherapy The role of chemotherapy in the management of cancer of the oral tongue is still unclear. Early tumors are not treated with this modality because of the high success of either radiation therapy or surgery. Patients who present with extensive primary lesions or with distant metastases and poor prognoses are good candidates for chemotherapy. Factors to consider if contemplating chemotherapy include stage of disease, general medical status, potential efficacy, and tolerance to adverse effects. A new strategy for using chemotherapeutic agents is concomitant chemoradiation. With this modality, chemotherapy is administered at the same time as radiation therapy. This approach has multiple benefits, which include synergism, radiosensitization, beneficial antiproliferative effects, possible improved locoregional control, and possible improved survival. Surgical therapyThe 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. 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. 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. Preoperative detailsThe patient's preoperative evaluation is initiated by obtaining consent for the procedure. The discussion includes the goals of the procedure, the estimated operative time, and a description of the postoperative course. This often necessitates presenting the information to family members who will assist in the patient's recovery. The surgeon presents a detailed plan of surgical management. With smaller tumors, peroral resections may impair tongue mobility, resulting in dysphagia or speech difficulties. With larger tumors for which a mandibulotomy or a mandibulectomy is required, the patient's airway may become an issue and the physician may need to consider a tracheotomy. The goal remains to excise the tumor in its entirety from a tridimensional standpoint, including a margin of normal-looking tissue. In these settings, a preoperative assessment by a speech therapist is beneficial to the patient so that expected difficulties can be discussed. Educate patients who present with clinical lymphadenopathy or those whose surgical plan includes a neck dissection about the procedure and about the expected difficulties, depending on which neck structures must be resected. In more extensive procedures, advise the blood bank about the potential need for a transfusion and request that the blood bank personnel type and cross-match the appropriate number of units. Obtain autologous blood from the patient preoperatively. In most cases, to expedite surgical management, usually the patient does not have enough time to build back sufficient reserves. Intraoperative detailsUse information obtained from the preoperative evaluation under anesthesia and the radiological imaging to plan the excision. Unless the tumor is very small, general anesthesia is necessary. In patients with more complex medical problems, a preoperative evaluation by the anesthesiologist provides additional information regarding potential medical issues that may arise during the surgery. Prophylactic antibiotics at the time of surgery are a good means of limiting the risk of infection in the perioperative period. Consider agents that cover microorganisms in the oral flora, especially anaerobes. The antibiotic dosage may depend on the patient's medical status, especially kidney function. For peroral resections, once the patient is under general anesthesia, all the edges of the tumor are carefully visualized. Palpation of the tumor helps assess the depth of infiltration and how much of the tongue substance must be resected. The area of excision includes a 5- to 10-mm margin of normal-looking soft tissue. Perform the excision with either a scalpel blade or electrocautery. The advantage of electrocautery is that bleeding is controlled as the resection is performed. Larger vessels may need to be controlled with ligatures. Once the resection is completed, samples of the wound bed are submitted to the pathologist for frozen section and tumor clearance. Because the defects are smaller, the tongue is usually closed in multiple layers on itself from posterior to anterior. For larger tumors (ie, T3, T4 lesions) that require a mandibulotomy, perform a tracheotomy early in the resection to allow for postoperative airway protection and care. Tracheotomy also improves the visibility of the tumor and helps define the margins of excision more precisely. If the tumor approaches or involves the gingiva, perform a mandibulectomy. McGregor and MacDonald demonstrated the mechanisms of mandibular involvement. In nonirradiated patients, the tumor crawls up the lingual plate and enters through the occlusal surface of both dentulous and edentulous mandibles. If the mandibular invasion is limited, the inferolateral mandible usually remains uninvolved and marginal mandibulectomy may be performed. The lingual cortex becomes the lateral margin, with local control rates similar to those achieved with a segmental mandibulectomy. The preservation of mandibular continuity markedly improves postoperative form and function. When the mandibular invasion is through the cortex, segmental mandibulectomy and appropriate glossectomy are required, followed by postoperative radiation therapy. Surgical reconstruction for smaller defects may be accomplished by primary closure and insertion of a skin graft. Larger defects may require a free flap. If limited mandibular involvement is present, a radial forearm flap provides proper bulk while not tethering the tongue to the floor of the mouth. Anterior mandibular segmental defects must be reconstructed to avoid the so-called "Andy Gump" deformity, a term coined in 1978 in a dental publication referring to the appearance of a chinless cartoon character from the early 20th century. This is best accomplished by using a fibula free flap with skin paddle, if needed. The fibula free flap has excellent bone stock that can support osseointegrated implants for dental restoration. Alternatives include a scapular or iliac crest free flap. The decision to use one or multiple microvascular and/or pedicled flaps depends on the functional status of the patient and the size of the defect. Final wound closure is accomplished with meticulous attention to the approximation of the wound edges after adequate hemostasis is completed. Place suction drains in the wound when indicated, and use irrigation to remove small clots and debris. Postoperative detailsFollowing a limited glossectomy, most patients require sufficient analgesia and may require a short course of postoperative antibiotics. Carefully examine the patient's wounds, and intensively monitor patients who underwent free flap reconstruction to assess for early flap failure. In cases in which a neck dissection is part of the surgical plan, carefully evaluate the skin flaps for wound dehiscence. Monitor the drain sites for the amount and type of drainage. Patients usually have postoperative odynophagia as a result of tongue pain and may require energy supplementation if unable to tolerate a soft diet. In cases of extensive resections, percutaneous feedings via a nasogastric or gastrostomy tube are advisable, at least until the wound edges have had sufficient time to epithelialize. For patients dependent on a tracheostomy, proper nursing care is necessary to prevent crust accumulation and tube obstruction. The nursing team may want to teach the patient tracheotomy tube care early in the recovery, familiarizing the patient and other caregivers with long-term care. Follow-upAll patients are monitored regularly following surgery to assess wound healing, the development of complications, and for recurrence of disease. If an ulcer develops in the surgical site, perform a biopsy because of the limited morbidity associated with this procedure. For patients with larger tumors for whom radiation therapy is part of treatment, consider early referral to a radiation therapist. Radiation therapy also may be considered for patients who are not surgical candidates but who experience disease recurrence. For excellent patient education resources, visit eMedicine's Cancer and Tumors Center. Also, see eMedicine's patient education article Cancer of the Mouth and Throat. COMPLICATIONSSection 7 of 11
Complications may be classified by type and timing of occurrence. Early postoperative complications include collection of blood or serum under the neck flaps or site(s) of reconstruction. Drains on high suction evacuate these fluids and keep the neck flaps in close apposition for faster wound healing. Wound dehiscence may result from infection, malnutrition, poor wound healing, or tissue necrosis. Gentle handling of the tissue and meticulous wound closure may prevent this. Proper donor and recipient site selection, perioperative use of anticoagulants, and close monitoring of the site of vascular anastomosis help prevent flap failure. Monitoring the vascular anastomoses may be difficult, and subtle changes in flow characteristics also may herald early signs of flap failure. Sometimes, signs of flap failure can be detected with the use of a portable Doppler ultrasound unit. Later changes may include an alteration in the turgor or color of the skin paddle of the flap. Early intervention by wound reexploration and revision of the vascular anastomosis may allow salvage of a failing flap. Salivary leaks or air leakage may occur when the mucosal incisions are not well approximated, potentially leading to fistulae and wound infection. Aggressive management of fluid collections minimizes the risk of fistulization, and small collections may be aspirated. Larger accumulations require reopening the wound and irrigating and cleaning the wound surfaces, followed by packing the surgical site. Late complications include skin or mucosal slough, exposure of the mandibulotomy site, nonunion, osteonecrosis, and fistula formation. Others include poor speech and swallowing function. If exposure of the carotid artery occurs as a result of tissue sloughing, bring in regional or distant tissue when the wound is clean to prevent carotid rupture. Management of mandibular exposure or nonunion depends on the severity of the problem. Solutions range from local wound care in limited cases to mandibular restabilization and reconstruction if hardware is exposed. OUTCOME AND PROGNOSISSection 8 of 11
For T1 and T2 lesions, radiotherapy using interstitial implants with or without external beam radiotherapy and surgical excision have equivalent results. The 5-year disease-free survival rate ranges from 80-90% for lesions treated with either modality. The long-term complications of radiation implants, including local necrosis and bone exposure, are more frequent than those associated with surgery. Surgery also reserves the option of radiation for the treatment of second primary lesions, which occur in up to 40% of cases. The 5-year survival rates for patients in stages III and IV are 30-50%, with lymph node metastasis decreasing the survival rate 15-30%. Treatment failure often occurs in the cervical lymph nodes, even for patients with an N0 neck. The incidence of occult cervical metastasis in carcinoma of the tongue correlates with the T stage. In a study from Spiro and Strong, the incidence of cervical metastasis increases progressively as the T stage advances. Of patients with T1 cancers, 20% had occult metastases, compared to 43% and 77% of patients with stages T2 and T3 disease, respectively. Elective radiation therapy is an option for the treatment of the N0 neck. Mendenhall et al demonstrated that elective neck radiation significantly reduces the rate of neck recurrence. Others have published conflicting studies. Meoz et al reported a 16.6% neck recurrence rate for patients receiving the traditional 50 Gy dose to the upper neck. Decroix and Ghossein reported a 14% rate of neck recurrence among 50 patients with squamous cell carcinoma of the oral tongue staged N0 who received radiation therapy. For patients with cancer of the oral tongue, elective treatment of the N0 neck is better than no treatment. This may take the form of either radiation therapy or surgery. Radiation therapy is preferable in individuals with poor health, but it has the associated adverse effects of mucositis and xerostomia and the risk of osteoradionecrosis. Surgery appears to provide better overall cure rates and allows for pathologic evaluation of the specimen for prognostication. To better evaluate prognosis and outcome, many studies have looked at the expression of various growth factors and tumor markers. In studying the overexpression of epidermal growth factor (EGFR) and cerb-B2, these 2 growth factors have not been found useful in predicting outcome and survival. FUTURE AND CONTROVERSIESSection 9 of 11
A number of issues remain controversial in the management of tongue cancer. The optimal radiation therapy schedule for managing small lesions in order to limit xerostomia, mucositis, and potential late complications (eg, osteoradionecrosis, fibrosis) is an ongoing debate. The addition of new chemotherapy agents may provide increased tumor sensitization to the radiation and may allow for dose limitation. The management of the N0 neck continues to be a source of open debate. Because of the relatively high incidence of occult disease, the preferred treatment of these patients is either of the 2 modalities. Possibly with newer imaging techniques on the horizon, physicians will be better able to identify smaller tumor foci and the number of patients staged as N0 will decrease. Finally, the greatest challenge remains in the field of tongue reconstruction. Numerous microvascular flaps have been described to give bulk and also sensation to the neotongue. Some even use motor reinnervation as a means to give some mobility to these tissues. Because of the complexity of integration of the intrinsic and extrinsic tongue musculature and the crucial role the tongue has in speech, taste, and deglutition, the ideal flap has yet to be identified. MULTIMEDIASection 10 of 11
REFERENCESSection 11 of 11
Malignant Tumors of the Mobile Tongue excerpt Article Last Updated: May 4, 2006 | ||||||||||||||||||||||||||||||||
