What is the recommended treatment for a 3 cm tongue ulcer with no lymph node (LN) involvement?

Management of a 3 cm Tongue Ulcer with No Lymph Node Involvement

For a 3 cm tongue ulcer with clinically negative lymph nodes, wide local excision (WLE) plus selective neck dissection of levels 1-4 is the recommended treatment due to the high risk of occult nodal metastases despite clinically negative examination.

Rationale for Treatment Recommendation

Tumor Characteristics and Risk Assessment

• A 3 cm tongue ulcer represents a significant lesion that falls into at least T2 classification
• Tongue cancers have high propensity for occult lymph node metastasis even when clinically node-negative
• Ulcerative lesions typically have more aggressive behavior than exophytic ones

Evidence Supporting Neck Dissection for cN0 Disease

• Studies show 15-20% of patients with clinically negative necks harbor occult metastases 1
• Elective neck dissection significantly reduces mortality due to lymph nodal metastasis compared to observation, particularly for T2 lesions (74.2% vs 41.2% 5-year disease-specific survival) 2
• The frequency of clinically occult lymph node metastases justifies elective neck dissection even when nodes are not palpable 3

Treatment Algorithm

Primary Tumor Management

1. Wide Local Excision (WLE) with 1-2 cm margins
   • Aim for histologically negative margins
   • Avoid mandibular resection unless there is obvious bone invasion 1

Neck Management

1. Selective Neck Dissection (levels 1-4)
   • Preferred over observation due to high risk of occult metastases
   • Cervical clearance is preferable to radical clearance for equivalent local control with better functional outcomes 1

Postoperative Management Based on Pathology Findings

• If margins negative and no nodal involvement: Observation may be sufficient
• If positive margins: Consider adjuvant radiation therapy with concurrent platinum-based chemotherapy 1
• If perineural invasion or lymphovascular invasion: Adjuvant radiation therapy 1
• If 2-4 positive nodes and/or ≤1 mm extranodal extension: Adjuvant radiation therapy 1
• If ≥5 positive nodes or >1 mm extranodal extension: Adjuvant radiation therapy with concurrent platinum-based chemotherapy 1

Important Considerations

Pitfalls to Avoid

• Undertreatment: Observation alone (option B) is inadequate for a 3 cm ulcerative lesion due to high risk of occult metastases
• Overtreatment: Bilateral neck dissection (option A) is not necessary for a unilateral primary tumor without clinical evidence of contralateral spread
• Inadequate Surgical Documentation: The operative note should fully describe anatomic boundaries of lymph node dissection 1

Quality Control Measures

• Ensure proper documentation of lymph node location (levels), size of lymph nodal masses, presence of extranodal spread, and number of involved nodes 4
• Postoperative specialist rehabilitation should be offered to patients 1

In conclusion, while options A (WLE + bilateral neck dissection) would be excessive and option B (WLE alone) would be insufficient, option C (WLE + selective neck dissection) represents the optimal approach for balancing oncologic control with functional preservation for this 3 cm tongue ulcer with clinically negative nodes.