Management of the Neck for Tongue Cancer

  • Tumors of the tongue:
    • Initially metastasize to levels I and II:
      • Lateral tongue tumors frequently metastasizing directly to level II nodes
    • Involvement of level V nodes:
      • In the absence of positive nodes in levels I to IV is rare:
        • However it is not unusual for nodes in level IV to be involved:
          • Hence even in elective neck dissections levels I to IV should be dissected
  • Like floor of mouth tumors:
    • The presence of lingual lymph nodes should be considered and either an in-continuity resection with the neck specimen or clearance of tissue above the mylohyoid conducted
  • Bilateral neck dissections:
    • Should be considered in tumours that extend to or beyond the midline.
  • The management of the neck in larger primary tumors:
    • Is usually straightforward since the neck is accessed for microvascular or pedicled flap reconstruction of the primary site
    • Management difficulties arise with smaller tumors amenable to peroral resection and local closure
  • It has been proposed that the increased incidence of nodal metastasis associated with tongue carcinoma:
    • May be due to contraction of tongue muscles promoting entry of cancer cells into the lymphatics
    • It is thought that mechanism by which tumor thickness is related to cervical metastasis:
      • Is that thicker tumors have access to wider lymphatics:
        • In which tumor emboli can form more readily
    • Although tumors arising on the lateral aspect of the tongue tend to be thicker than those of the ventral aspect of the tongue:
      • This may not manifest as a greater risk of cervical metastasis, since the ‘critical thickness’ for tumors of the floor of mouth is less than other oral sites
  • Elective neck dissection or elective neck radiotherapy:
    • Should be considered for tumors thicker than 3 mm to 4 mm:
      • T2 or greater in dimension and T1 tumors that demonstrate poor histological features:
        • Poor differentiation
        • Double DNA aneuploidy
        • Degree of differentiation at the advancing front
  • Elective neck dissection:
    • Significantly improves loco-regional control:
      • It has been demonstrated that conducting an END reduces regional recurrence from 47% in ‘watch and wait’ patients to 9% if END is conducted
  • END has been shown by some to improve five-year survival:
    • The five-year survival of patients undergoing therapeutic neck dissection following a ‘watch and wait’ policy being 35% as opposed to 69% when an elective neck dissection is conducted
      • Others, however, have not demonstrated a survival advantage
#Arrangoiz #CancerSurgeon #MountSianiMedicalCenter #MSMC #Miami #Mexico

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