Glossectomy 

Updated: Feb 08, 2016
  • Author: Larry Leonard Myers, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Pre-Procedure

Background

The tongue is a highly specialized, vital organ of the oral cavity. Resecting a part or all of the tongue presents a wide array of challenges that require the surgeon to avoid, limit, or restore the severe functional impairments to gustation, mastication, deglutition, and phonation.

This purpose of this chapter is to review the embryology, anatomy, and the most common malignancy of the tongue. The authors also address the clinical evaluation, surgeries and reconstructions, post-operative course, and prognosis of patients undergoing glossectomy.

Embryology

The tongue appears during the fourth week of development with the appearance of the tuberculum impar, a mesenchyme swelling in the floor of the primitive pharynx cranial to the foramen cecum. The anterior two-thirds of the tongue is formed from the two lateral swellings (derived from the first pharyngeal arch) that develop on either side of the tuberculum impar. These lingual buds fuse together and form the median sulcus of the tongue. The posterior one-third of the tongue arises from the hypobranchial eminence overgrowth of the copula. The copula is formed by the ventromedial parts of the second pharyngeal arch and the cranial part of the third pharyngeal arch. The hypobranchial eminence is formed by the ventromedial parts of the third and fourth pharyngeal arches.

The epithelium of the tongue develops from foregut endoderm. Most tongue muscles develop from myoblasts that migrate from the occipital myotomes. The connective tissue, lymphatic vessels, and blood vessels of the tongue arise from pharyngeal arch mesenchyme.

Histology

The tongue is lined by masticatory stratified squamous epithelium. The magnitude of physical forces during function dictates the degree of epithelial keratinization of the tongue in comparison to other areas within the oral cavity.

Relevant anatomy

Gross Anatomy

From anterior to posterior, the tongue has 3 surfaces: tip, body, and base. The tip is the highly mobile, pointed anterior portion of the tongue. Posterior to the tip lies the body of the tongue, which has dorsal (superior) and ventral (inferior) surfaces (see the image below).

Tongue, dorsal view. Tongue, dorsal view.

Muscles

The 8 muscles of the human tongue are classified as either intrinsic or extrinsic. The 4 intrinsic muscles act to change the shape of the tongue and are not attached to any bone. The 4 extrinsic muscles act to change the position the tongue and are anchored to bone. They are the genioglossus, hyoglossus, styloglossus, palatoglossus.

Vascular supply

The tongue receives its blood supply primarily from the lingual artery, a branch of the external carotid artery. The floor of the mouth also receives its blood supply from the lingual artery. The triangle formed by the intermediate tendon of the digastric muscle, the posterior border of the mylohyoid muscle, and the hypoglossal nerve is sometimes called Pirogov-Belclard 's triangle. The secondary blood supply to the tongue is from the tonsillar branch of the facial artery and the ascending pharyngeal artery.

Nerve supply

Taste for the anterior two thirds of the tongue is supplied by the facial nerve (chorda tympani, CN VII). General sensation of the anterior two thirds of the tongue is supplied by the lingual nerve, which is a branch of CN V3. The glossopharyngeal nerve (CN IX) provides general sensation for the posterior one-third tongue. All intrinsic and extrinsic muscles of the tongue are supplied by the hypoglossal nerve (CN XII), except for one of the extrinsic muscles, palatoglossus, which is innervated by CN X of the pharyngeal plexus.

For more information about the relevant anatomy, see Tongue Anatomy.

Physiology of the swallow

Initiation of swallow begins with containing the food bolus within the oral cavity. Freely mobile tongue is then able to make contact with the anterior palate, form the bolus, and initiate posterior movement of the base of tongue toward the pharyngeal wall, which propels food bolus toward the back of the throat. Elevation of the hyoid and larynx allows opening of the upper esophageal sphincter and bolus is passed.

Pathology

Squamous cell carcinoma (SCC)

Greater than 95% of tongue cancers are squamous cell carcinomas (SCC). Treatment consideration of other, less common malignancies of the tongue (adenocarcinoma, adenoid cystic carcinoma) and sarcomas (alveolar soft part sarcoma) is beyond the scope of this chapter. The principles established for partial and total glossectomy for SCC can be generally applied to other malignancies.

SCC of the tongue generally presents in the fifth and sixth decade of life and is more common in males. [1, 2] Smoking tobacco and ethanol abuse are strongly associated with the development of SCC of the tongue, and patients who abuse both tobacco and ethanol have a 6-fold to 15-fold increased risk of developing cancer. [3, 4, 5]

Lymph node metastasis

The lymphatic spread of tongue SCC generally occurs in an orderly manner, involving first the uppermost (levels I-II), then middle (levels II-III), and finally the lower cervical lymph nodes (level IV). Lymphatic drainage for the tongue includes the internal jugular, subdigastric, omohyoid, submandibular, and submental nodal basins (levels I-III).

The anterior pathway drains the tip of the oral tongue and primarily drains to level III. The lateral group drains the lateral one third of the dorsum of the tongue from the tip to the circumvallate papillae to submandibular, and internal jugular nodal basins and occasionally the submental node basin (levels I-III). The central pathway drains the central two thirds of the tongue. These vessels drain to the submental region (level I) or the upper cervical chain nodal basin via the sublingual nodes (level III). [6] Primary lesions of the tongue that approach midline often drain to bilateral nodal basins, as significant lymphatic crossover exists in this region. [7]

Patient evaluation

Patients who present for the evaluation of tongue cancer require a detailed history and thorough physical examination. The clinician should ascertain the presence and duration of symptoms such as pain, bleeding, otalgia, odynophagia, dysphagia, and dysarthria. The history should document risk factors such as the use of tobacco and alcohol, recent dietary habits, weight loss, medical co-morbidities, and family history of disease.

Physical examination is performed to evaluate the pretreatment condition of the patient, including extent of primary tumor, presence and location of cervical lymph node metastases, as well as screening for synchronous primary malignancies. Fiberoptic laryngoscopy should be performed in the office for examination of the airway which is often compromised in advanced disease as well as assessment of laryngeal involvement.

Biopsy of tongue lesions can usually be performed in the clinical setting with local anesthesia or may be performed under general anesthesia during formal panendoscopy. Palpable neck masses or large metastatic cervical lymph nodes are usually amenable to fine-needle aspiration biopsy. Ultrasound-guided fine-needle aspiration is often used in obtaining a diagnosis when suspected cervical disease is difficult to localize and has been reported to have superior sensitivity and specificity when compared to traditional fine needle aspiration. [8] Open surgical biopsy of suspected cervical metastatic disease is generally contraindicated.

Diagnostic imaging

Computed tomography

Computed tomography (CT) with intravenous contrast is the most commonly used radiographic study for tongue cancer. Contrast CT allows for a 3-dimensional evaluation of the primary tumor giving invaluable information regarding related anatomic structures and the extent of local invasion. In general, patients diagnosed with advanced SCC of the tongue should also undergo contrast CT of the chest to evaluate for pulmonary metastatic disease.

CT remains the imaging modality of choice when evaluating the clinically N0, obese, or previously-irradiated neck for cervical metastatic disease.

Magnetic resonance imaging

Magnetic resonance imaging (MRI) offers superior soft tissue resolution when compared to CT. Increased diagnostic accuracy in extension of soft tissue primary lesion as well as improved accuracy for cervical lymph node staging has prompted some authors to recommend routine MRI scanning for head and neck malignancy. [9] MRI offers an excellent imaging modality, with accuracy superior to conventional CT scanning when evaluation of the extent of invasion of the primary tumor is required. Large lesions located within the tongue and floor of mouth that are subject to dental and osseous tomographic artifact are particularly amenable to MRI. MRI is especially useful in cases that exhibit perineural invasion and can improve accuracy related to extension of disease in these lesions. Despite this increased accuracy, as in the case of CT, MRI offers insufficient accuracy to detect micrometastatic disease.

Positron emission tomography

Positron emission tomography (PET) is a functional imaging technique that uses a radio-labeled tracer, 18-fluoro-2-deoxyglucose (18-FDG), to detect metabolically active cells, as is the case with cancer. PET has increased accuracy (true positives) for the detection of head and neck malignancy, post-therapy tumor surveillance, and evaluation for cervical/distant metastatic disease. [10, 11, 12, 13]

With a known primary lesion in the advanced stage, PET offers little advantage over CT or MRI. PET offers inferior resolution for evaluating the extent of the primary lesion and should be combined with CT to improve diagnostic accuracy. Currently, the limit of detection correlates to a resolution of approximately 5 mm. Although PET offers significant promise in the evaluation of the N0 neck in early stage disease, in patients with advanced tongue cancers, the status of the neck is only of prognostic significance.

Panendoscopy

Panendoscopy (direct laryngoscopy, esophagoscopy, bronchoscopy) is frequently helpful when evaluating tongue cancers. The extent of the primary tumor is evaluated, particularly the relationship of the tumor to the midline, base of tongue, and mandible. Biopsies are obtained at the time of the panendoscopy if the histologic diagnosis has yet been established. Panendoscopy is also used to rule out synchronous malignancies.

Tongue SCC staging

All patients evaluated for head and neck malignancy should be staged according the American Joint Committee on Cancer (AJCC) TNM staging system for oral cavity lesion, as shown below. [14]

AJCC TNM Classification: Oral cavity SCCA

Primary Tumor (T)

  • TX - Primary tumor cannot be assessed
  • T0 - No evidence of primary tumor
  • Tis - Carcinoma in situ
  • T1 - Tumor 2 cm or less in greatest dimension
  • T2 - Tumor more than 2 cm but not more than 4 cm in greatest dimension
  • T3 - Tumor more than 4 cm in greatest dimension
  • T4 (lip) - Tumor invades through cortical bone, inferior alveolar nerve, floor of mouth, or skin of face, ie, chin or nose
  • T4a (oral cavity) - Tumor invades through cortical bone, into deep (extrinsic) muscle of tongue (genioglossus, hyoglossus, palatoglossus, and styloglossus) maxillary sinus, or skin of face
  • T4b - Tumor involves masticator space, pterygoid plates, or skull base and/or encases internal carotid artery

Regional Lymph Nodes (N)

  • NX - Regional lymph nodes cannot be assessed
  • N0 - No regional lymph node metastasis
  • N1 - Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension
  • N2 - Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension; or in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension
  • N2a - Metastasis in single ipsilateral lymph node more than 3cm but not more than 6cm in greatest dimension
  • N2b - Metastasis in multiple ipsilateral lymph nodes, none more than 6cm in greatest dimension
  • N2c - Metastasis in bilateral or contralateral lymph nodes, none more than 6cm in greatest dimension
  • N3 - Metastasis in a lymph node more than 6cm in greatest dimension

Distant Metastasis (M)

  • MX - Distant metastasis cannot be assessed
  • M0 - No distant metastasis
  • M1 - Distant metastasis

AJCC Staging System: Oral Cavity SCCA

Stage Grouping

  • 0, Tis, N0, M0
  • I, T1, N0, M0
  • II, T2, N0, M0
  • III, T3, N0, M0
  • T1, N1, M0
  • T2, N1, M0
  • T3, N1, M0
  • IVA, T4a, N0, M0
  • T4a, N1, M0
  • T1, N2, M0
  • T2, N2, M0
  • T3, N2, M0
  • IVB, any T, N3, M0
  • T4b, any N, M0
  • IVC, any T, any N, M1

Factors affecting prognosis

Tumor thickness

In general, increased tumor size and thickness is significantly predictive of decreased survival and increases the rate of locoregional recurrence. Measuring tumor thickness and pattern of invasion in patients with early oral cancer may allow for the identification of those patients with more aggressive disease. Patients with tumor diameter greater than 1.5 cm or greater than 5 mm of tumor thickness may then be considered for more aggressive adjuvant therapy and elective neck dissection regardless of stage due to increased risk for cervical lymph node metastasis. [15, 16]

MRI is sufficiently accurate to determine tumor thickness of oral cavity SCC, although histologic evaluation remains the standard. [17, 18] Although tumor thickness reliably predicts regional nodal metastasis and decreased survival, specific treatment strategies based on tumor thickness have yet to be evaluated due to the wide range of factors related to prognosis among patients with oral cavitySCC. [19] In the case of advanced-stage oral cavity SCC (stages III, IV), tumor thickness is generally not a consideration in treatment planning as the depth usually exceeds 5 mm and patients generally receive aggressive surgery with neoadjuvant and/or adjuvant chemoradiotherapy.

Perineural invasion

Perineural invasion has been associated with increased risk local recurrence and cervical metastasis and is generally thought to be an independent predictor of survival for patients with oral cavity SCC. [20, 21, 22] The presence of even small peripheral nerve involvement has been associated with decreased survival. If pathologically confirmed, this should prompt strong consideration for a full course of postoperative radiotherapy to treat the primary tumor as outcomes related to locoregional recurrence are poor. [23, 24]

Positive surgical margins

Microscopic residual tumor resulting from positive surgical margins statistically increases local recurrence and mortality when treating SCC of the head and neck. Patients treated with surgery as the primary modality exhibit significantly improved local control rates if a negative surgical margin is obtained. Surgeons performing resections for advanced primary oral cavity SCC should strive for a minimum of 1 cm margin, with 2–3 cm margins preferred, to minimize the likelihood of positive margins. Positive surgical margins either at the primary site or within the neck after neck dissection require the use of postoperative radiotherapy to improve outcomes. Two-year disease-free survival has been reported to improve from 33.6% to 75.6% in patients with positive surgical margins who received postoperative radiotherapy (≥62.5 Gy). [25]

Cervical metastasis

The presence of cervical lymph node metastasis has been repeatedly cited as the most significant factor that portends decreased survival and locoregional recurrence in tongue SCC. Furthermore, cervical lymph node metastasis located at more distant levels of the neck (levels III/IV), or in the contralateral neck, also tend to have significantly decreased survival rates. Overall 5-year survival rates when comparing patients without evidence of cervical lymph node metastasis to those with positive nodal disease have been reported as 42.8% and 17.5% respectively. [26, 27, 28, 29, 30, 31, 32] Patients who present with advanced stage oral cavity SCC generally present with lymph node metastasis by definition. The presence of cervical lymph node metastasis should be considered an ominous sign and should prompt early, aggressive treatment in order to optimize outcomes.

Extracapsular extension

Cervical lymph node metastasis which exhibit extracapsular extension has a statistically decreased overall survival. [33] The presence of nodal extracapsular extension is also concerning for cervical recurrence after therapy. Advanced stage tongue SCC may present with extensive cervical nodal disease that increases the likelihood of extracapsular extension. Patients with multiple lymph nodes exhibiting extracapsular extension generally have an extremely poor prognosis. [33]

Decision factors in treatment planning

Tumor thickness

In general, increased tumor size and thickness is significantly predictive of decreased survival and increases the rate of locoregional recurrence. Measuring tumor thickness and pattern of invasion in patients with early oral cancer may allow for the identification of those patients with more aggressive disease. Patients with tumor diameter greater than 1.5 cm or greater than 5 mm of tumor thickness may then be considered for more aggressive adjuvant therapy and elective neck dissection regardless of stage due to increased risk for cervical lymph node metastasis. [15, 16]

MRI is sufficiently accurate to determine tumor thickness of oral cavity SCC although histologic evaluation remains the standard. [17, 18] Although tumor thickness reliably predicts regional nodal metastasis and decreased survival, specific treatment strategies based on tumor thickness have yet to be evaluated due to the wide range of factors related to prognosis among patients with oral cavity SCC. [19] In the case of advanced stage oral cavity SCC (stages III, IV), tumor thickness is generally not a consideration in treatment planning, as the depth usually exceeds 5 mm and patients generally receive aggressive surgery with neoadjuvant and/or adjuvant chemoradiotherapy.

Perineural invasion

Perineural invasion has been associated with increased risk local recurrence and cervical metastasis and is generally thought to be an independent predictor of survival for patients with oral cavity SCC. [20, 21, 22] The presence of even small peripheral nerve involvement has been associated with decreased survival. If pathologically confirmed, this should prompt strong consideration for a full course of postoperative radiotherapy to treat the primary tumor as outcomes related to locoregional recurrence are poor. [23, 24]

Positive surgical margins

Microscopic residual tumor resulting from positive surgical margins statistically increases local recurrence and mortality when treating SCC of the head and neck. Patients treated with surgery as the primary modality exhibit significantly improved local control rates if a negative surgical margin is obtained. Surgeons performing resections for advanced primary oral cavity SCC should strive for a minimum of 1 cm margin, with 2–3 cm margins preferred, to minimize the likelihood of positive margins. Positive surgical margins either at the primary site or within the neck after neck dissection require the use of postoperative radiotherapy to improve outcomes. Two-year disease-free survival has been reported to improve from 33.6% to 75.6% in patients with positive surgical margins who received postoperative radiotherapy (≥62.5 Gy). [25]

Cervical metastasis

The presence of cervical lymph node metastasis has been repeatedly cited as the most significant factor that portends decreased survival and locoregional recurrence in tongue SCC. Furthermore, cervical lymph node metastasis located at more distant levels of the neck (levels III/IV), or in the contralateral neck, also tend to have significantly decreased survival rates. Overall 5-year survival rates when comparing patients without evidence of cervical lymph node metastasis to those with positive nodal disease have been reported as 42.8% and 17.5%, respectively. [26, 27, 28, 29, 30, 31, 32] Patients who present with advanced stage oral cavity SCC generally present with lymph node metastasis by definition. The presence of cervical lymph node metastasis should be considered an ominous sign and should prompt early, aggressive treatment in order to optimize outcomes.

Extracapsular extension

Cervical lymph node metastasis that exhibits extracapsular extension has a statistically decreased overall survival. [33] The presence of nodal extracapsular extension is also concerning for cervical recurrence after therapy. Advanced stage tongue SCC may present with extensive cervical nodal disease, which increases the likelihood of extracapsular extension. Patients with multiple lymph nodes exhibiting extracapsular extension generally have an extremely poor prognosis. [33]

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Technique

Approach

Oncologic resection should include at least 2 cm margin from the macroscopic border of the cancer. Cold instruments may be inadequate for hemostasis owing to the vascularity of the tongue. Therefore, Bovie electrocautery is preferred. For further options, either an ultrasonic or thermal scalpel can also be used.

Nearly all tongue lesions can be accessed via the combined oral and cervical approaches. [34] If a mandibulectomy is required for adequate surgical margins, a lip-splitting procedure need not be performed in combination, as this may increase postoperative morbidity. If the lip split with median or paramedian mandible osteotomy is performed, then complications from this procedure may be decreased by combining the paramedian approach (including stair step) with rigid fixation of the osteotomy with titanium plates/screws. Lingual artery ligation is often required for large tongue resections. Careful attention to the location of the hypoglossal nerve is critical to preserve the function of the remainder of the tongue in order to optimize speech and swallowing outcomes.

For the purposes of this chapter, the authors classify glossectomy and associated tongue reconstructions into the following categories:

  1. Partial Glossectomy (less than one third of tongue)
  2. Hemiglossectomy (one third to half of tongue)
  3. Near-total glossectomy (half to three quarters of tongue)
  4. Total glossectomy (greater than three quarters of tongue)

Reconstruction

The goals of reconstruction include restoration of mastication, deglutition, and speech, as well as an acceptable aesthetic result. In order to achieve these goals, multi-specialty reconstructive and rehabilitative efforts are paramount. When deciding between reconstructive options of the tongue, the most important consideration is the size of the defect, but location may also play an important role. [35]

The normal swallow begins with containing the food bolus within the oral cavity. Greater volumes of tongue resection are associated with decrease in swallowing function. [36, 37, 38] Lack of adequate tongue bulk leads to premature spillage into the pharynx. [39] Presently, no reconstructive options offer complete restoration of the form and function of the tongue. Regional and free-flap options differ regarding the amount of bulk provided, mobility afforded, technical difficulty and operative time, and functional outcomes.

Partial glossectomy (less than one third of tongue)

Proposed defects of less than 25% of the tongue (see the first image below) have shown better results with primary closure (see the second image below) compared to local or free flap coverage in regards to oral transit times and swallowing efficiency. [40] These patients often have minimal loss of speech and swallowing function. [41, 42, 43] According to a study of 24 patients who underwent a total or subtotal glossectomy, preserving >1/2 the tongue base prevents taste disorder. [44] In addition, a split-thickness or full-thickness skin graft may be applied to the resected area to minimize scar contracture of the tongue.

T1N0 SCC, right lateral tongue, T1N0 SCC, right lateral tongue,
Primary closure of right lateral tongue defect wit Primary closure of right lateral tongue defect with 3-0 chromic suture.

Hemiglossectomy and near-total glossectomy (from 25-75% of tongue)

The preferred method of reconstruction of hemiglossectomy and near-total glossectomy defects is free tissue reconstruction (see the images below) Significant advantages to free-tissue transfer procedures include the ability to select the donor site that matches the requirements of the defect, large quantities of tissue availability including skin and fascia with the possibility of sensory/motor restoration via microneurorrhaphy techniques.

Another significant advantage is the ability to provide donor tissue that has not been subjected to locoregional therapy such as radiation, thus offering superior vascularity and healing potential. Pedicled flaps, such as the platysma flap and pectoralis flap are examples of regional flaps that may also be used.

Right hemiglossectomy reconstruction with radial f Right hemiglossectomy reconstruction with radial forearm free flap.
Intraoperative photo of reconstructed right hemigl Intraoperative photo of reconstructed right hemiglossectomy defect.

Pedicled flaps

  • Platysma flap: A reliable, thin myocutaneous regional flap. It is based on the platysma branch of the facial artery. Reconstruction of floor of mouth and buccal mucosa is achievable for defects of up to 5 cm. This flap should not be used when sternocleidomastoid muscle is removed in a neck dissection.
  • Pectoralis flap: A workhorse of oral cavity reconstruction. It is a fan-shaped musculocutaneous flap based on the thoracoacromial artery. Advantages include its ease of harvest, primary donor site closure, and large skin territory. Some consider its major disadvantage is its bulky size.

Free flaps

  • Radial forearm flap: A combination of being thin and pliable flap yet containing a rich vascularity make this one of the most widely used microvascular free flaps in reconstructive surgery of the head and neck. It is used primarily as fasciocutaneous flap, but can also be used as a fascial flap. It is based on the radial artery and its fasciocutaneous branches.
  • Anterolateral thigh free flap: A versatile fasciocutaneous flap is based on the descending branch of the lateral femoral circumflex artery (see the images below). Low donor site morbidity is an advantage of this flap with primary closure of the donor site possible with flaps up to 8 cm wide. Contouring of the flap is eased by insertion of the vascular pedicle into the mid-portion of the skin paddle.
    Left thigh with skin markings for proposed anterol Left thigh with skin markings for proposed anterolateral thigh (ALT) free flap.
    Anterolateral thigh flap elevation with lateral ci Anterolateral thigh flap elevation with lateral circumflex femoral artery pedicle.
  • Rectus Abdominis free flap: A muscle flap up to 30 cm long that can be harvested with skin and fascia, supplied by the deep inferior epigastric artery originating of the external iliac vessels. Advantages of this flap are its long vascular pedicle, ability to provide bulk as a neotongue, and its tendinous inscriptions which can be sutured to the mandible.

Total glossectomy

When performing a total glossectomy for advanced tongue cancers (see first image below), a tongue “pull though” from the oral cavity into the neck can be used (see the second image below). This allows for complete visualization of the macroscopic borders of the cancer. This technique is contraindicated for tumor extension to periosteum of lingual mandible surface. Larger or total glossectomy defects benefit from reconstruction with the rectus abdominis or anterior lateral thigh free flap due to the need for increased bulk, which is difficult to achieve with the radial forearm flap. [45, 46, 47, 48]

T4N0 squamous cell carcinoma, left lateral tongue. T4N0 squamous cell carcinoma, left lateral tongue.
Tongue specimen "pulled through" from oral cavity Tongue specimen "pulled through" from oral cavity into neck.

Pedicled Flaps

  • Pectoralis flap (see image below)
    Total glossectomy reconstruction with pectoralis f Total glossectomy reconstruction with pectoralis flap.

Free Flaps

  • Anterolateral thigh free flap (see images below)
    Total glossectomy reconstruction with anterolatera Total glossectomy reconstruction with anterolateral thigh flap.
    Total glossectomy reconstruction with anterolatera Total glossectomy reconstruction with anterolateral thigh flap.
  • Rectus Abdominis free flap

Surgical management of the neck

The treatment of the neck is critical in patients with tongue SCC. It is generally accepted that routine surgical dissection of the node-positive neck is required for advanced stage oral cavity SCC. [49, 50] Tongue SCC has an extremely high rate (60-80%) of clinically evident and occult cervical lymph node metastasis to levels I-III, with a moderate risk of level IV involvement. [51, 52]

Surgical management of the ipsilateral neck in tongue SCC consists of the modified radical neck dissection including levels I, II, III, and IV with preservation of the spinal accessory nerve, internal jugular vein, and sternocleidomastoid muscle. [53, 54] T3 or T4 lesions or lesions approaching the midline require bilateral modified radical neck dissection due to the risk of contralateral lymph node metastasis. [55] The risk of level V cervical lymph node metastasis in tongue SCC is extremely low and therefore the utility of level V dissection may is questionable for many these lesions. [56, 57, 58]

Additional adjunctive radiotherapy is warranted for increased regional control of disease in the presence of cervical metastasis.

Complications

Free flap failure ranges from 0-15% in the immediate postoperative period. [59] Postoperative assessment should focus on restoration of swallow and speech function. Rates of G-tube dependence range from 3-17%. [60, 61] In a cohort of 20 patients, none were G-tube dependent after free flap reconstruction of tongue base, and only 5% demonstrating aspiration event. [62] This is similar to a 3% aspiration rate in heterogeneous group of primary and secondary closures. [63]

Surveillance

Regardless of the extent of treatment for tongue SCC, patients require close clinical surveillance. Wound care, complications, or morbidity resulting from therapy may require more frequent clinical appointments. Current practice guidelines from the American Head and Neck Society regarding the clinical surveillance of patients who have been treated for advanced oral cavity/oropharyngeal SCC are outlined below: [64]

  • 1st year post treatment: 1-3 month interval
  • 2nd year post treatment: 2-4 month interval
  • 3rd year post treatment: 3- 6 month interval
  • 4th and 5th years: 4- 6 month interval
  • After 5 years: Every 12 month interval

Physical examination including fiberoptic laryngoscopy should be performed at each interval to assess the response to therapy as well as monitor for recurrent and/or second malignancies. CT or MR may be obtained as clinically indicated to investigate for occult malignancy and to monitor the neck for cervical metastasis. PET is an excellent surveillance instrument as it represents a functional imaging modality, rather than a static imaging modality as in the case of CT or MR, and is currently recommended by many investigators. [65, 66] PET has been shown to be highly effective in detecting locoregional recurrence as well as distant metastases after multimodality therapy for head and neck SCC.

Recurrence

Recurrence following therapy for tongue SCC is an extremely discouraging development. Advanced staged cancers are at a significantly higher risk of locoregional recurrence. [67] Patients with recurrent disease are candidates for salvage therapy such as surgery, additional chemotherapy, and radiotherapy depending on the primary therapy administered. There is some evidence that surgical salvage may offer a slight outcome advantage compared to other modalities such as radiation and chemotherapy. Despite the type of salvage therapy, survival outcomes in this patient population are somewhat dismal and have been reported to range between approximately 15-35% at 5 years. [68] Patients should be cautiously counseled regarding the morbidity of salvage therapy and the limited chance for cure prior to initiating salvage therapy for recurrent advanced stage oral cavity SCC.

Quality of Life

Several objective scales have been developed for evaluation of quality of life in head and neck cancer patients. Increasing emphasis has been placed on quality of life with the improved locoregional control afforded by these therapies. There is some difficulty obtaining prospective quality of life data. [69] Prior to therapy, evaluation should include input by the oncologic and reconstructive surgeon, oral/maxillofacial surgeon, general dentist, speech/swallowing therapist, physical therapist, and nutritionist.

Conclusion

Cancer of the tongue provides many challenges due to its highly specialized function. The defect left by resecting these tumors dramatically impact speech, swallowing, and general quality of life. A variety of options are available to the head and neck surgeon for reconstruction. Of paramount importance is coordination of multi-specialty reconstructive and rehabilitative efforts.

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