What is the management approach for a non-healing tongue lesion with associated enlarged submandibular glands?

Management of Non-Healing Tongue Lesion with Enlarged Submandibular Glands

A non-healing tongue lesion with enlarged submandibular glands requires urgent tissue diagnosis through biopsy of the tongue lesion, followed by cross-sectional imaging (CT or MRI with contrast) to assess the extent of disease and nodal involvement, as this presentation is highly suspicious for oral cavity malignancy with regional metastasis.

Initial Diagnostic Approach

Tissue Diagnosis

• Biopsy the tongue lesion immediately to establish histologic diagnosis, as non-healing oral lesions warrant high suspicion for squamous cell carcinoma or other malignancies 1.
• The biopsy should include adequate depth to assess tumor thickness, as this directly impacts risk of regional metastases 1.

Imaging Evaluation

• Obtain contrast-enhanced CT or MRI of the neck to evaluate the primary lesion extent and characterize the submandibular gland enlargement 1.
• MRI without and with IV contrast provides superior soft tissue contrast resolution for delineating tumor extent, perineural invasion, and distinguishing tumor from inflammatory changes 1.
• Imaging must assess:
  • Tumor thickness and depth of invasion (critical for staging and neck management decisions) 1
  • Mandibular involvement or periosteal adherence 1
  • Perineural invasion along motor or sensory nerves 1
  • Cervical lymph node involvement, particularly levels I-III 1

Ultrasound-Guided Fine-Needle Aspiration

• Consider ultrasound-guided FNA of enlarged submandibular nodes if imaging shows suspicious lymphadenopathy 1, 2.
• This helps distinguish between primary submandibular gland tumors (30% malignant) versus metastatic disease from the tongue lesion 3, 2.
• Note that submandibular gland involvement in oral cavity cancers typically occurs through direct extension or metastasis to level I lymph nodes, not primary gland malignancy 4.

Surgical Management Based on Diagnosis

If Malignant Oral Cavity Cancer Confirmed

Primary Tumor Resection:

• Perform en bloc resection with adequate margins (≥5 mm clear margin from invasive tumor front on final pathology) 1.
• Intraoperative frozen section margin assessment should be used when clearance is uncertain 1.
• Resection may require partial mandibulectomy if tumor is adherent to mandibular periosteum or shows bone involvement on imaging 1.

Neck Management:

• For tongue cancers with enlarged submandibular nodes, perform ipsilateral neck dissection including at minimum levels I-III 1.
• Level Ib involvement occurs in 40% of clinically node-positive oral cavity cancers 5.
• For cN+ disease, extend dissection to levels I-V as needed, since level V involvement occurs in up to 40% of therapeutic neck dissections for parotid malignancies (similar principles apply) 1.
• The submandibular gland should be removed en bloc with level Ib contents when there is clinical or radiographic evidence of nodal disease in this region 4, 5.

Critical Surgical Principles:

• Assess for perineural invasion intraoperatively; if suspected, dissect nerve proximally and distally with frozen section confirmation of clearance 1.
• For tumors approaching or crossing midline, consider contralateral submandibular dissection 1.
• Achieve clear resection margins with 1.5-2 cm of visible and palpable normal mucosa when possible 1.

If Primary Submandibular Gland Tumor

• Submandibular gland excision with wide margins is required for both benign and malignant tumors 3, 2.
• Approximately 30% of submandibular gland tumors are malignant, with adenoid cystic carcinoma and adenocarcinoma being most common 3.
• For high-grade or T3-T4 submandibular malignancies, perform elective neck dissection of levels I-III even if clinically N0 1.
• Malignant submandibular tumors have 61.5% mortality rate, emphasizing need for aggressive initial treatment 3.

Adjuvant Therapy

Postoperative Radiotherapy Indications:

• Offer adjuvant radiotherapy for: 1
  • Close margins (<5 mm) or positive margins
  • High-grade histology
  • T3-T4 primary tumors
  • Perineural invasion
  • Lymphovascular invasion
  • Multiple positive nodes or extranodal extension

Elective Neck Irradiation:

• Consider elective neck radiation for cN0 disease with T3-T4 tumors or high-grade malignancies, as risk of microscopic involvement exceeds 33% for submandibular gland tumors with these features 1.
• Elective neck doses ≥46 Gy show trend toward improved regional control 1.

Common Pitfalls to Avoid

• Do not delay biopsy while pursuing extensive imaging workup; tissue diagnosis drives all subsequent management 1.
• Do not assume enlarged submandibular glands are reactive/inflammatory without tissue confirmation, as metastatic involvement significantly alters prognosis and treatment 4, 5.
• Do not perform inadequate neck dissection in clinically node-positive disease; level V involvement is common and requires comprehensive dissection 1.
• Do not attempt submandibular gland preservation when level Ib nodes are clinically or radiographically involved, as this compromises oncologic outcomes 4, 5.