What is the initial treatment approach for tongue cancer?

Initial Treatment Approach for Tongue Cancer

For tongue cancer, the primary treatment approach is surgical resection for resectable tumors, with radiotherapy or chemoradiotherapy reserved for adjuvant treatment or for patients who are medically inoperable or refuse surgery. 1

Assessment and Staging

Before initiating treatment, proper assessment is essential:

• Complete physical examination including neck palpation
• Biopsy for histological confirmation
• Imaging studies:
  • CT scan or MRI to assess primary tumor and regional lymph nodes
  • Chest imaging (minimum chest X-ray) to evaluate for distant metastases
  • FDG-PET/CT for high-risk tumors 1

Treatment Algorithm Based on Tumor Location

Oral Tongue (Anterior Two-Thirds)

1. Early Stage (T1-T2, N0):

   • Primary surgical resection with appropriate margins 1
   • Selective neck dissection guided by tumor thickness, even for clinically N0 disease 1
   • For tumors with depth of invasion <5mm and cT1N0, active surveillance of the neck may be considered 1

2. Advanced Stage (T3-T4, N0-N3):

   • Surgery followed by risk-adapted adjuvant therapy 1
   • Adjuvant radiotherapy (58-63 Gy) for high-risk features:
     • pT3-T4 tumors
     • Close margins
     • Perineural infiltration
     • Lymphovascular spread
     • Multiple positive lymph nodes 1
   • Adjuvant chemoradiotherapy (66 Gy with cisplatin) for:
     • Positive margins (R1 resection)
     • Extracapsular nodal spread 1

Base of Tongue (Posterior Third)

1. Early Stage (T1-T2):

   • Primary radiation therapy with or without brachytherapy is preferred due to better functional outcomes 2
   • Patients treated with radiation have consistently better performance status scores for eating in public, speech understandability, and normalcy of diet compared to surgery 2

2. Advanced Stage (T3-T4):

   • Combined modality approach with radiation and chemotherapy 3
   • For T4 tumors, combination surgery and radiotherapy may provide better local control 3

Special Considerations

Unresectable Disease (T4b and/or unresectable lymph nodes)

• Concomitant chemoradiotherapy is the treatment of choice 1
• Induction chemotherapy followed by RT or chemoradiotherapy for responders 1

Medically Inoperable Patients or Those Refusing Surgery

• External beam RT or brachytherapy can be used as primary treatment for selected cases 1
• Dose of 44-64 Gy to the neck for T1-2, N0 disease 1

Functional Outcomes and Quality of Life

• Surgical treatment of oral tongue cancer generally provides good functional outcomes due to advances in reconstruction using microvascular techniques 3
• For base of tongue cancer, radiation therapy provides better performance status than surgery for both early and advanced disease 2
• Functional scores remain high for all T stages treated with radiation for base of tongue cancer, but deteriorate with more advanced T stages for patients treated with surgery 2

Post-Treatment Follow-Up

• Regular clinical examinations to monitor for recurrence and second primaries
• Thyroid function monitoring after neck irradiation (TSH every 6-12 months) 3
• Most recurrences occur within the first 2 years after treatment 1

Common Pitfalls to Avoid

1. Delayed initiation of adjuvant therapy: Postoperative treatment should start within 6-7 weeks after surgery 1

2. Neglecting dental evaluation: Dental evaluation and rehabilitation before radiotherapy is necessary to prevent complications 1

3. Overlooking nutritional status: Significant malnutrition (>10% weight loss in 6 months) requires nutritional support before treatment 1

4. Inadequate assessment of depth of invasion: This is a critical factor in determining the need for neck dissection in early-stage oral tongue cancer 1

5. Inappropriate treatment selection for base of tongue cancer: Quality of life outcomes strongly favor radiation therapy over surgery, particularly for advanced disease 2