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

Management of 3 cm Tongue Ulcer with No Lymph Node Involvement

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

Rationale for Treatment Selection

The management of tongue ulcers with clinically negative necks requires careful consideration of the risk of occult metastases, which is present in 15-20% of patients with clinically negative necks 1. For a 3 cm lesion, which would likely be classified as T2, the risk is particularly significant.

Why Selective Neck Dissection is Necessary

• A selective neck dissection (levels 1-4) is preferred over observation for the following reasons:
  • High risk of occult metastases in tongue carcinomas 1
  • Improved survival outcomes compared to observation alone 2
  • The 2014 study by Journal of Cranio-Maxillo-Facial Surgery demonstrated that patients with T2 tongue carcinomas who underwent elective neck dissection had significantly better 5-year disease-specific survival (74.2%) compared to those under observation (41.2%) 2

Surgical Approach Details

• Wide Local Excision:

  • Should include 1-2 cm margins around the ulcer 1
  • Goal is to achieve histologically negative margins 1
  • Avoid mandibular resection unless there is obvious bone invasion 1

• Selective Neck Dissection:

  • Levels 1-4 lymph nodes should be removed 1
  • Cervical clearance is preferable to radical clearance for equivalent local control with better functional outcomes 1

Adjuvant Therapy Considerations

Based on post-surgical pathology findings, adjuvant therapy may be necessary:

• If positive margins are found: Consider adjuvant radiation therapy with concurrent platinum-based chemotherapy 1
• If perineural invasion or lymphovascular invasion is present: Adjuvant radiation therapy is recommended 1
• If positive nodes are found: Adjuvant therapy based on extent of nodal involvement 1

Documentation Requirements

The operative note should fully describe:

• Anatomic boundaries of lymph node dissection
• Lymph node location (levels)
• Size of lymph nodal masses
• Presence of extranodal spread
• Number of involved nodes 1

Common Pitfalls to Avoid

1. Undertreatment: Choosing observation alone or WLE without neck dissection for a 3 cm tongue ulcer significantly increases the risk of nodal recurrence and mortality 2

2. Overtreatment: Performing bilateral neck dissection when there is no clinical indication would increase morbidity without clear benefit

3. Inadequate margins: Failure to achieve histologically negative margins significantly worsens outcomes 1

4. Delayed rehabilitation: Postoperative specialist rehabilitation should be offered promptly to optimize functional outcomes 1

The evidence strongly supports option C (WLE + selective neck dissection of levels 1-4) as the most appropriate treatment for a 3 cm tongue ulcer with clinically negative neck, balancing oncologic control with functional preservation.