How should a bleeding base-of-tongue squamous cell carcinoma be managed?

Management of Bleeding Base-of-Tongue Squamous Cell Carcinoma

Immediate Hemorrhage Control

For active bleeding from base-of-tongue squamous cell carcinoma, apply topical hemostatic agents directly to the bleeding surface, using thrombin-based products (1000 units/mL) in conjunction with absorbable gelatin sponge when oozing blood and minor bleeding from capillaries is present and standard surgical techniques are ineffective. 1

• Direct pressure with gauze soaked in topical thrombin or epinephrine (1:10,000) provides initial control for minor bleeding 1
• Do not inject hemostatic agents directly into the circulatory system as this may cause thrombosis 1
• For brisk arterial bleeding, topical agents are contraindicated and require urgent surgical or interventional radiology consultation 1

Risk Assessment for Surgical Intervention

Patients on systemic anticoagulation represent the highest bleeding risk group and require careful perioperative management with coordination of anticoagulation discontinuation, potential bridging therapy, and risk stratification using HAS-BLED score or Caprini Risk Assessment Model. 2

• Preoperative imaging with contrast-enhanced CT or MRI is mandatory to assess parapharyngeal fat invasion, external carotid artery branch proximity, and internal carotid artery relationship to tumor 2
• Tumor effacing parapharyngeal fat and abutting medial pterygoid muscle indicates unsuitability for surgical resection and warrants nonsurgical primary treatment 2
• Standard bleeding risk mitigation includes preoperative anticoagulation discontinuation, perioperative hypertension control, intraoperative mono/bipolar cautery with vascular clips, and transcervical ligation of external carotid branches 2

Definitive Treatment Decision Algorithm

All therapeutic decisions must be made by a multidisciplinary team including head and neck surgery, radiation oncology, and medical oncology, as there are no randomized trials to guide management in oropharyngeal cancer. 2

For Early Stage Disease (T1-T2):

• External radiotherapy, radiotherapy plus brachytherapy, or surgery followed by postoperative radiotherapy provide equivalent local control rates (90% for T1, 75-80% for T2) 2
• Single-modality treatment is preferred when possible 2
• Concurrent chemoradiotherapy followed by brachytherapy achieves 79.9% locoregional control at 3 years with 80.9% overall survival 3

For Locally Advanced Disease (T3-T4):

• Primary surgical treatment followed by radiotherapy or chemoradiotherapy is the preferred approach for T3/T4 base-of-tongue cancers 2
• Surgery achieves local control in 82% of patients with stage III/IV disease, with 5-year disease-specific survival of 56% 4, 5
• For T3 tumors, radiotherapy combined with brachytherapy (65-72%) is superior to radiotherapy alone (37-67%) 2
• Definitive radiotherapy (median 74.4 Gy) with altered fractionation schedules yields 85.5% local control and 71.5% cause-specific survival at 5 years 6

Surgical Considerations When Indicated

Bilateral neck dissection is mandatory for base-of-tongue cancers due to 23% risk of contralateral occult metastases in clinically N0 necks and 47% rate of contralateral metastatic disease in clinically positive cases. 7, 5

• Occult cervical metastases occur in 61% of clinically N0 necks, with 80% showing extracapsular spread in base-of-tongue cancers 7
• Ipsilateral neck nodes demonstrate metastatic disease in 84% of cases 5
• Postoperative radiotherapy is mandatory for positive margins (R1/R2), perineural infiltration, lymphatic infiltration, >1 invaded lymph node, or extracapsular extension 2
• Postoperative chemoradiotherapy is required for R1 resection and extracapsular rupture 2

Pretreatment Preparation

• Obtain p16 immunohistochemistry on all biopsies as surrogate marker for HPV status, though treatment strategy remains the same regardless of HPV status 2, 8
• Arrange stomatological evaluation with tooth extraction when required before radiotherapy to prevent osteoradionecrosis 8
• Implement MASCC/ISOO daily oral care plan with ultra-soft toothbrush, fluoride toothpaste, and bland rinses (0.5% sodium bicarbonate/0.9% saline three times daily) 2
• Postoperative radiotherapy or chemoradiotherapy must start within 6-7 weeks of surgery 2

Critical Contraindications

In patients with very high risk of intraoperative/postoperative bleeding due to tumor factors (extensive parapharyngeal invasion, carotid encasement) or patient factors (uncontrolled coagulopathy, history of major bleeding), transoral robotic surgery should not be pursued and nonsurgical treatment options should be strongly considered. 2