What is the recommended treatment for a patient with stage IVA (stage four A) tongue squamous cell carcinoma, status post (s/p) hemiglossectomy and mandibulectomy with reconstruction?

Postoperative Adjuvant Therapy for Stage IVA Tongue Squamous Cell Carcinoma

For a patient with stage IVA tongue squamous cell carcinoma who has undergone hemiglossectomy and mandibulectomy with reconstruction, postoperative chemoradiotherapy with high-dose cisplatin (100 mg/m² every 3 weeks) to 66 Gy is the standard treatment when high-risk pathologic features are present, specifically R1 resection margins or extracapsular spread. 1

Risk-Stratified Adjuvant Treatment Approach

High-Risk Features Requiring Chemoradiotherapy

Postoperative concurrent chemoradiotherapy is mandatory when pathology demonstrates: 1

• R1 resection (microscopically positive margins) 1
• Extracapsular spread/extension from lymph nodes 1

For these high-risk features, the regimen consists of:

• Radiation dose: 66 Gy 1
• Cisplatin: 100 mg/m² administered on days 1,22, and 43 of radiation 1
• Alternative for cisplatin-unfit patients: Weekly cisplatin 40 mg/m² has been shown non-inferior to high-dose cisplatin in the postoperative setting 1

Intermediate-Risk Features Requiring Radiotherapy Alone

Postoperative radiotherapy alone (without chemotherapy) is indicated for: 1

• pT3-T4 tumors 1
• Perineural infiltration 1
• Lymphovascular invasion 1
• More than one invaded lymph node (without extracapsular extension) 1
• Close surgical margins 2

Radiation doses for intermediate-risk features: 1

• 63-64 Gy when multiple risk factors present 1
• 58 Gy when only one risk factor present 1

Critical Timing Requirements

Treatment must begin within strict timeframes to optimize outcomes: 1

• Postoperative radiation/chemoradiation should start within 6-7 weeks after surgery 1, 2
• The entire treatment package (surgery plus adjuvant therapy) must be completed within 11 weeks 1

Technical Radiation Delivery Standards

All patients must receive intensity-modulated radiation therapy (IMRT) or volumetric modulated arc therapy (VMAT) 1, as this represents the current standard of care for head and neck radiation to minimize toxicity while maintaining disease control.

Alternative Chemotherapy Regimens

For patients unable to tolerate cisplatin, validated alternatives include: 1

• Carboplatin combined with 5-fluorouracil 1
• Cetuximab concurrent with radiation (though this provides inferior outcomes compared to cisplatin-based therapy) 1

The cetuximab regimen when used consists of: 3

• Initial dose: 400 mg/m² as 120-minute infusion one week prior to radiation 3
• Subsequent doses: 250 mg/m² weekly as 60-minute infusion for duration of radiation (6-7 weeks) 3

Common Pitfalls and Caveats

Critical pathology review is essential: The decision between radiation alone versus chemoradiation hinges entirely on accurate pathologic assessment of margins and extracapsular extension. Any uncertainty should prompt multidisciplinary discussion. 1

Avoid treatment delays: The 6-7 week window to start adjuvant therapy is not flexible—delays beyond this timeframe significantly compromise outcomes. 1 Nutritional optimization, dental rehabilitation, and wound healing concerns must be addressed proactively to meet this timeline. 1

Functional rehabilitation must be aggressive: Given the extent of resection (hemiglossectomy and mandibulectomy), patients face significant swallowing dysfunction risk. 4 Prior radiation therapy, adjuvant chemoradiation, and the composite resection with mandibulectomy are all independent risk factors for failure to achieve total oral diet. 4 Early and intensive swallow therapy is mandatory, not optional.

Weekly cisplatin at standard doses (30-40 mg/m²) controversy: While weekly cisplatin at 40 mg/m² has shown non-inferiority in postoperative settings 1, weekly cisplatin at 30 mg/m² was demonstrated to be inferior to 3-weekly high-dose cisplatin in a randomized trial. 1 Therefore, if weekly dosing is chosen, 40 mg/m² weekly is the minimum acceptable dose. 1

Surveillance After Adjuvant Therapy

Active clinical surveillance protocol: 2

• Physical examination every 1-3 months for years 1-2 2
• Imaging only as clinically indicated for concerning findings 2
• TSH monitoring at 1,2, and 5 years post-neck irradiation 1, 2