What is the recommended management for a patient with T3 N2 squamous cell cancer of the tongue after undergoing hemiglossectomy (partial removal of the tongue)?

Management of T3 N2 Squamous Cell Cancer of the Tongue After Hemiglossectomy

Adjuvant postoperative radiotherapy with concurrent cisplatin-based chemotherapy is mandatory for T3 N2 tongue cancer following hemiglossectomy. 1, 2

Adjuvant Radiation Therapy Parameters

Standard radiation dosing and timing:

• Deliver 60-66 Gy to the tumor bed and bilateral neck regions using once-daily fractionation of 2 Gy per fraction 1, 2
• The higher dose range (60-66 Gy) is indicated given the advanced T3 stage and N2 nodal disease 1, 2
• Radiation must begin within 6 weeks of surgery to optimize outcomes, as delays beyond this timeframe significantly compromise disease control 1, 2

Target volumes:

• Treat the tumor bed (hemiglossectomy site) and bilateral cervical lymph node regions 2
• Bilateral neck treatment is essential for N2 disease, even if nodes were surgically addressed, due to high risk of microscopic residual disease 2, 3

Concurrent Systemic Therapy

Chemotherapy is strongly recommended:

• High-dose cisplatin at 100 mg/m² on days 1,22, and 43 is the preferred regimen (Category 1 evidence) 4, 2
• Concurrent chemoradiation provides superior locoregional control and survival compared to radiation alone for advanced-stage disease with N2 nodal involvement 4
• The combination increases toxicity but significantly improves disease-free and overall survival in patients with extracapsular spread or multiple positive nodes 4

Pathologic Features That Mandate Dose Escalation

Review surgical pathology for high-risk features:

• Positive or close margins (<5 mm) require the full 60-66 Gy dose 1, 2
• Extracapsular nodal extension mandates concurrent chemoradiation at the higher dose range 4, 1
• Multiple positive lymph nodes (≥2) indicate need for aggressive adjuvant therapy 1
• Perineural invasion, lymphovascular invasion, or depth of invasion >4 mm are additional adverse features requiring full-dose treatment 1

Treatment Algorithm Based on Pathologic Findings

If final pathology shows:

• Positive margins (tumor on ink) or >1 mm extracapsular extension or ≥5 positive nodes: Deliver 60-66 Gy with concurrent cisplatin 100 mg/m² 1, 2
• Close margins (1-3 mm), 2-4 positive nodes, or ≤1 mm extracapsular extension: Deliver 60-66 Gy; consider concurrent cisplatin based on multidisciplinary discussion 1, 2
• Perineural or lymphovascular invasion alone: Deliver 56-60 Gy without chemotherapy may be adequate, though higher doses are reasonable given T3 N2 stage 1

Critical Pitfalls to Avoid

Common errors that compromise outcomes:

• Delaying radiation start beyond 6 weeks postoperatively significantly worsens locoregional control and survival 1, 2
• Using unilateral radiation fields when N2 disease is present leaves contralateral neck at risk, particularly for tongue cancers with midline lymphatic drainage 2, 3
• Underestimating the need for concurrent chemotherapy in N2 disease—bilateral or multiple nodal involvement represents high-risk disease requiring combined modality therapy 2
• Failing to deliver adequate radiation dose (60-66 Gy) for T3 disease, as lower doses compromise local control 1, 2
• Not completing the full course of radiation or chemotherapy due to toxicity concerns, which significantly compromises disease control 1

Surveillance and Long-Term Management

Post-treatment monitoring:

• TSH levels should be monitored every 6-12 months following bilateral neck irradiation, as hypothyroidism occurs in 20-25% of patients 1, 2
• Close clinical follow-up is essential for early detection of locoregional recurrence, which occurs in approximately 40% of advanced tongue cancers 3
• Monitor for second primary tumors of the upper aerodigestive tract, which develop in approximately 12% of patients 3
• Assess for radiation-induced xerostomia and consider IMRT techniques to reduce salivary gland toxicity 4