ORAL TONGUE CANCER

In deciding on treatment modalities for oral tongue cancer, the same factors are applicable as for most other head and neck sites. T1 and T2 lesions can be treated by surgery or radiation therapy, and T3 and T4 lesions do best with combination therapy. Control rates of 86% for T1 and 75% for T2 lesions are accepted for radiation therapy treatment alone. Because of the high complication rate associated with curative doses, Wendt et al. (28) suggested that the policy of initial surgery with postoperative radiation therapy should be reserved for patients with a suspected high rate of local or neck failure. Techniques for radiation therapy delivery vary. Wendt et al. (28) suggested that interstitial therapy is necessary, but Wang (29) suggested that the intraoral cone electron beam boost technique provides a superior cure rate compared with interstitial implant for T1 and T2 oral lesions.

Whatever the radiotherapeutic technique used, controversy remains over whether prophylactic neck therapy is necessary for T1 lesions, as it is for T2 lesions. It is accepted that a certain subgroup of t1 lesions requires prophylactic neck therapy, although the factors that define this group are still an issue. As mentioned earlier in the discussion of prognostic factors, some consider depth of penetration to be the factor that dictates the necessity of neck therapy. Others have recognized the poor prognostic relationship with neck metastases when the primary lesion is greater than 1 cm, but they are unsure as to whether this is truly the appropriate indicator.

If the surgeon opts for surgical resection of an early tongue cancer, the aforementioned issues must be considered regarding prophylactic neck therapy. Although issues have been raised concerning laser versus conventional excision of these lesions, the methodology is purely a technical choice, because the survival rate of about 80% does not change according to technique. Laser provides no distinct oncologic advantages over a standard surgical scalpel.

The treatment of stage III and IV disease requires combination therapy to control locoregional disease better than either surgery or radiation therapy alone. Several clinical trials that have included oral tongue lesions as a small subset of the overall patient base have shown benefit from the addition of chemotherapy to standard radiation therapy regimens (16,17 and 18). However, more specific data are needed before the advantage of chemotherapy for these lesions is proven. Overall survival rates for patients with stage III and stage IV disease range from 30% to 35%.

The extent of resection is obviously dictated by the size of the lesion and its anatomic locus. As in all head and neck reconstruction, the defect closure techniques vary from primary closure to rotation of a distant flap. Greater cosmetic and functional debilitation is suffered when part of the mandible must be resected. Although the surgeon must advise the patient on the speech and swallowing deficits that accompany oral cavity resections, especially those involving the tongue and the floor of the mouth, some basic principles can be followed to minimize the level of debilitation. Tongue flaps, which provide the worst functional reconstructive results, must be avoided in view of the many choices available. Using a split-thickness skin graft where possible provides good functional results (30). Unfortunately, when the defects include much of the floor of the mouth and tongue, either a myocutaneous or free flap (e. g., pectoralis major or radial forearm) must be used. For these patients, oral competence becomes a significant issue.

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