What is the recommended treatment approach for a patient with T2 (tumor size), N2B (lymph node involvement), cM0 (clinical metastasis) tongue cancer?

Treatment of T2N2B Tongue Cancer

For T2N2B tongue cancer, the standard treatment is surgical resection of the primary tumor with bilateral neck dissection followed by adjuvant postoperative radiotherapy to the tumor bed and bilateral neck regions at 56-60 Gy (or 60-66 Gy if adverse features are present). 1

Primary Treatment Approach

Surgical Management

• Wide local excision (partial glossectomy) with adequate margins (≥5 mm) is the cornerstone of treatment for the primary T2 tongue lesion 2
• Bilateral neck dissection is mandatory for N2B disease (bilateral lymph node involvement), as this represents significant nodal burden requiring comprehensive surgical management 3
• The bilateral approach is essential because N2B staging indicates contralateral nodal involvement, which carries high risk for regional failure 3
• Approximately 23% of base of tongue cancers staged N0 have histological node invasion in contralateral neck nodes, underscoring the importance of bilateral treatment in N2B disease 3

Adjuvant Radiation Therapy (Required)

Postoperative radiotherapy is mandatory for T2N2B disease due to the significant nodal involvement, which represents a major risk factor for locoregional recurrence 1

Radiation Dosing Protocol:

• Standard dose: 56-60 Gy to the tumor bed and bilateral neck regions using once-daily fractionation of 2 Gy per fraction 1
• Escalated dose: 60-66 Gy if adverse pathologic features are present, including:
  • Microscopically positive margins 1
  • Extracapsular nodal extension 1
  • Multiple positive nodes (which is inherent in N2B disease) 1

Treatment Fields:

• Bilateral radiation fields are required for N2B disease given the bilateral nodal involvement 1
• Treatment should encompass the tumor bed and all involved/at-risk lymph node regions bilaterally 1

Consideration of Concurrent Chemoradiation

Concurrent systemic therapy (cisplatin) with radiation should be strongly considered for T2N2B disease given the high-risk features of bilateral nodal involvement 1

• The presence of N2B disease represents particularly significant risk for locoregional recurrence 1
• High-dose cisplatin at 100 mg/m² on days 1,22, and 43 is the preferred regimen when concurrent chemoradiation is used 4
• This approach is supported by evidence showing improved locoregional control in patients with extracapsular spread and multiple positive nodes 4

Critical Timing Considerations

Radiation therapy must begin within 6 weeks of surgery to optimize outcomes, as delays beyond this timeframe negatively impact disease control 1

Surveillance and Long-term Management

Monitoring Protocol:

• TSH levels every 6-12 months following neck irradiation, as hypothyroidism occurs in 20-25% of patients receiving bilateral neck radiation 1, 2
• Regular assessment for xerostomia and other radiation-induced complications 1

Recurrence Patterns:

• Regional recurrences (which are more likely with N2B disease) carry significantly worse prognosis than local recurrences (5-year disease-specific survival: 22% vs 86%) 5
• Most recurrences occur within the first 2 years (78%), with median time to recurrence of 12 months 5

Common Pitfalls to Avoid

• Failing to perform bilateral neck dissection in N2B disease, which would leave contralateral disease untreated 3
• Underestimating the need for adjuvant radiation in node-positive disease, particularly with bilateral involvement 1
• Delaying radiation therapy start beyond 6 weeks postoperatively 1
• Using unilateral radiation fields when bilateral nodal disease is present 1
• Inadequate surgical margins (<5 mm), which would necessitate dose escalation to 60-66 Gy 1, 2

Expected Outcomes

• Overall survival and non-recurrence rates are significantly influenced by nodal status, with node-positive disease having worse prognosis than node-negative disease 3
• Extracapsular nodal extension, which is common in N2B disease (53.5% of node-positive cases), may be present and requires aggressive combined modality treatment 3
• The recurrence rate for tongue cancer overall is approximately 41.7%, with higher rates in advanced nodal disease 3