Treatment of the Primary Site of a Squamous Cell Carcinoma of the Tongue

Resection of the tumor:
- With a 1 cm margin in three dimensions:
  - Should be conducted if surgery is the treatment of choice
The use of ultrasonography :
- To aid in assessment of surgical clearance had been advocated by some:
  - Particularly for the deep margin
Frozen section:
- Can be used (its my practice) but some centers do not routinely used it:
  - Even with apparently adequate margins during surgery:
    - 10% of resections may demonstrate histologically positive margins
The aim of reconstruction of the oral tongue following resection:
- Is to ensure maximum function of the residual tongue tissue:
  - Since the complex function of the tongue cannot be replicated with current reconstructive techniques
- Preservation of the tip of the tongue:
  - While maintaining oncologically sound resection margins:
    - Helps maximize postoperative function
The use of monopolar electrocautery:
- Cutting through mucosa changing to coagulation when in muscle, or the harmonic scalpel:
  - Helps reduce bleeding during the resection:
    - However this is at the cost of lack of feel afforded by the use of scalpel or scissors
If both lingual vessels are resected:
- Then the viability of the tip of tongue remnant should be carefully assessed:
  - Sacrifice of both hypoglossal nerves results in a nonfunctioning tongue tip
Small lesions may be removed with a laser and allowed to heal by secondary intention
T1 and small T2 primary tumors:
- May be excised with a vertical wedge and the defect closed primarily:
  - If the defect does not extend to significantly to include the floor of mouth
- Many larger lesions benefit from free flap reconstruction of the defect:
  - Usually with a radial free forearm flap:
    - Although the anterolateral thigh free flap is being used more frequently
  - The skin paddle of the chosen free flap:
    - Should be fashioned so as not to restrict residual tongue function and should hopefully augment swallowing
  - Typically, the reconstruction should be of the same size, or slightly smaller than the defect created by the resection
  - Care should be taken in the design of the flap:
    - When the defect extends to include adjacent sites:
      - Such as the soft palate or floor of mouth
  - The mobile tongue and floor of mouth:
    - Should be ‘separated’ in the reconstruction:
      - To minimize restriction of movement of the residual tongue
  - Thin radial free flaps may have their bulk increased by extending fascial flaps beyond the skin island:
    - The fascial flaps then being folded and buried underneath the epithelial reconstruction
- Reconstruction of large resections:
  - May be accompanied by measures aimed to improve postoperative function:
    - Such as static laryngeal suspension to the mandible and cricopharyngeal myotomy
- Once the specimen is removed, it is examined for clearance and orientated for the pathologist:
  - A digital photograph being useful
Radiotherapy as the primary treatment modality can be used in certain situations:
- Has been advocated since it conserves tongue volume and morphology:
  - Brachytherapy being considered preferable to external beam radiotherapy:
    - Osteoradionecrosis of the mandible is a recognized complication of brachytherapy of the tongue:
      - Up to 9% developing some form of osseous complication
    - The use of brachytherapy to the primary site:
      - Requires either surgery or external beam radiotherapy to the neck in an elective or therapeutic manner:
      - When surgery is not conducted as the primary treatment:
        
        Valuable prognostic information is lost:
        
        Since the primary tumor is not examined histologically:
        
        This makes the decision as to whether to conduct an END more difficult
      - It has been suggested that surgery is superior to brachytherapy in the management of stage I / II tongue cancer:
        
        By conducting surgery as the primary treatment modality, radiotherapy is kept in reserve for either poor prognostic indicators of the resected specimen, for management of recurrence or management of second primaries which commonly occur at a later date