Unanswered Questions on the Optimal Extent of Tongue Cancer Resections
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Unanswered Questions on the Optimal Extent of Tongue Cancer Resections Bipin T Varghese 1 Received: 18 December 2019 / Accepted: 28 April 2020 # Indian Association of Surgical Oncology 2020
Abstract Owing to the site- and stage-dependent molecular changes beyond the excised surgical margins of mucosal head and neck squamous cell cancers [HNSCC], an absolute cutoff for safe margins is difficult to define. Entrapment of the primary tumor in a specified compartment by a barrier clearance concept can circumvent this to a considerable extent, but it is not possible in all sites. A case of recurrent squamous cell cancer (SCC) of the tongue which had undergone wide excision of the lesion twice and later required a total laryngectomy because of crossover of the recurrent disease to the preepiglottic space and thereby to the glottissupraglottic region is presented as an example to illustrate this predicament. Keywords Mucosal HNSCC . Optimal margins . Extramarginal molecular changes . Compartment resections
Repeated surgery for multiple metachronus primary carcinomas of the tongue is a daunting task and often presents a difficult therapeutic dilemma to the head and neck disease management team. A 51-year-old ex-smoker with Eastern Cooperative Oncology Group (ECOG) performance status (PS) 2 presented to us with moderately differentiated squamous cell carcinoma (MDSCC) of the left lateral border of the tongue, staged as T2 N1 M0 on 8/9/2011. On examination, there was an ulceroproliferative growth of size 3 × 3 cm on the left lateral border, 4 cm from the tip of the tongue. The floor of mouth was free and the posterior limit of the ulcer was palpable. A 2 × 2-cm-sized lymph node was palpable at level 2. Wide excision of the lesion was done with an extended supraomohyoid neck dissection. The final pathological TNM was pT2N2bM0, the tumor had a depth of infiltration (DOI) of 1.8 cm, the tumor margins were free, and level 3 and 5 nodes were positive. Post-operative radiotherapy was given to both sides of the neck to the dose of 60 Gy with an electron boost to the lower neck. He was disease-free till 16/10/2018 when he presented with a lesion at the right lateral border of the tongue of size 3 × 2.5 cm extending from the tip to the base of tongue with palpable posterior limit and minimal encroachment to the * Bipin T Varghese [email protected] 1
Head and Neck Surgery Unit, Surgical Services, Regional Cancer Centre, Thiruvananthapuram, Kerala 695011, India
floor of the mouth, crossing the midline with no nodes, which was biopsy-proven to be MDSCC.ECOG was 1 and after a delay of 1 month due to the indecision of the patient, we did a wide excision of the lesion and reconstruction with a nasolabial island flap [1] harvested from right side (Fig. 1), and the final HPR showed DOI of 0.8 cm with adequate tumor margins. After 8 months of close follow-up, he was found to have an ulceroproliferative growth involving both lingual and laryngeal surfaces of the epiglottis and aryepiglottic folds on both sides with slough i
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