What are the guidelines for surgical treatment of tongue cancer?

Guidelines for Tongue Cancer Surgery

For tongue cancer, surgical treatment should be the primary approach for early-stage disease (T1-T2), while advanced stages (T3-T4) may require multimodality treatment including surgery followed by radiation therapy or chemoradiation. 1

Initial Assessment and Staging

• Complete clinical examination should document tumor characteristics (size, location, exophytic/infiltrating/ulcerative nature) and assess for infiltration of adjacent structures 1
• Biopsy is required for histological confirmation 1
• Evaluation of cervical lymph nodes (presence, sites, dimensions, mobility, number) is essential 1
• Standard imaging includes chest X-ray and orthopantomography 1
• Optional examinations include CT/MRI (for suspected deep muscle/bone involvement), cervical ultrasonography, panendoscopy, and bronchoscopy 1

Surgical Approaches by Tumor Stage and Location

Early Stage Disease (T1-T2)

• For T1-T2N0 tongue cancer: Single-modality treatment with surgery is recommended 1

  • Minimally invasive approaches (transoral laser microsurgery or transoral robotic surgery) are preferred when feasible 1
  • Negative surgical margins are critical for local control (100% local control with negative margins vs 36% with positive margins) 2
  • For well-lateralized tumors, unilateral treatment may be considered 3

• Management of the neck:

  • With the exception of T1-T2 glottic cancer, ipsilateral selective neck dissection (bilateral for near-midline tumors) or sentinel node biopsy is recommended for cT1-T2 tumors treated with primary surgery 1
  • Sentinel node biopsy provides better quality of life over neck dissection in the first 3 months after surgery 4

Advanced Disease (T3-T4)

• For T3-T4 tongue cancer: Surgery followed by adjuvant therapy is recommended 1

  • Primary surgical treatment of advanced base of tongue cancer offers excellent functional outcomes, local control (94%), and disease-specific survival (86.7% at 3 years) 5
  • For T4 tumors, surgical treatment is associated with significantly better survival (55%) compared to chemoradiation (25%) or radiation alone (0%) 1

• Reconstruction considerations:

  • Flap reconstruction becomes increasingly necessary when glossectomy resection exceeds 45mm to maintain tongue function 4
  • The specific type of reconstructive flap does not significantly influence long-term quality of life 4

Specific Guidelines by Anatomical Subsite

Base of Tongue

• For T1-T3 disease: Surgery with or without radiotherapy, external radiotherapy, or radiotherapy plus brachytherapy all provide similar local control rates (70-90%) 1
• For T4 tumors: Combination of surgery and radiotherapy may offer an advantage 1
• Aggressive surgical approach with postoperative radiotherapy or chemoradiotherapy for stage III-IV disease provides excellent functional outcome and local control 5

Tonsillar Fossae and Anterior Pillars

• For T1-T2 disease: External radiotherapy, radiotherapy plus brachytherapy, or surgery followed by postoperative radiotherapy provide equivalent local control rates (90% for T1, 75-80% for T2) 1
• For T3 tumors: Combination of radiotherapy and brachytherapy (65-72%) is better than radiotherapy alone (37-67%) 1
• For T4 tumors: No clear consensus on optimal approach, but failure rates are higher than for T3 tumors 1

Soft Palate and Uvula

• For T1-T2 disease: Surgery, radiotherapy, or radiotherapy plus brachytherapy provide equivalent local control rates (70-100% for T1, 60% for T2) 1
• For T3-T4 disease: No consensus on optimal approach 1
• If surgical margins are narrow (<5mm) or invaded, additional radiotherapy is recommended 1

Adjuvant Therapy Considerations

• Postoperative radiotherapy should be delivered to the tumor bed and involved lymph node regions at 56-60 Gy in the absence of positive margins and extracapsular nodal extension 3
• If microscopically positive margins or extracapsular nodal extension are present, the dose should be increased to 60-66 Gy 3
• Delaying the start of radiation therapy beyond 6 weeks after surgery can negatively impact outcomes 3

Common Pitfalls to Avoid

• Failure to achieve negative margins significantly reduces local control (100% with negative margins vs 36% with positive margins) 2
• Delaying adjuvant therapy beyond 6 weeks post-surgery compromises outcomes 3
• Multimodality treatment with surgery and radiotherapy for limited disease should generally be avoided due to higher complication rates and poorer functional results 1
• Most recurrences (78%) occur within the first 2 years, with local recurrences (63%) being more common than regional recurrences 6
• Patients with regional recurrences have significantly worse prognosis than those with local failures (5-year disease-specific survival: 22% vs 86%) 6