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The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at The Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature.
Current
Management of Squamous Cell Carcinoma of the Base of the Tongue
Oropharyngeal cancer remains a disease of high morbidity and mortality, but treatment is improving. About 4000 new cases are diagnosed in the United States each year. Males have a higher incidence than females, but the number of cases in women is rising. Another current trend is that the disease is affecting younger patients: many cases are being diagnosed in the fifth or sixth decades of life rather than at an elderly age. Regardless of age or sex predilections, the disease clearly is associated with tobacco use, and the amount of exposure to the carcinogen is directly proportional to the level of risk for developing the disease. Although the mechanism is not yet clear, evidence exists that alcohol consumption is also a risk factor, both by itself and when combined with tobacco use. Anatomy The surface of the base of tongue appears irregular and bumpy owing to scattered submucosal lymphoid follicles. The mucous membrane itself is actually smooth compared to the dorsum of the oral tongue. The surface of the base of the tongue is nearly parallel to the posterior pharyngeal wall. The musculature of the base of the tongue is continuous with that of the oral tongue and the floor of the mouth anteriorly. Resection of the tongue base, whether transoral or transcervical, requires consideration of the neurovascular bundle, consisting of the lingual vessels and the hypoglossal nerve. A recent Laryngoscope study from the Massachusetts Eye and Ear by Lauretano and colleagues presents a range of measurements to be considered as a guideline to the position of this bundle with respect to soft tissue and bony landmarks. The tongue base neurovascular bundle (NVB) is seen to maintain a close relationship to the superior aspect of the hyoid bone and to lie midway between the tongue midline and lateral tongue and inner mandible margins. The authors do caution that lingual anatomy and its locoregional relationships may vary significantly. The study shows the location of the tongue base NVB to lie quite inferiorly, within 1.5 cm of the hyoid bone (mean distance 0.9cm). In the transverse dimension, the bundle lies approximately midway between the innner mandible and lateral tongue margins (2.18 cm and 1.1cm, respectively) and the tongue midline. Longer tongue length yielded larger transverse distances from the NVB to both the foramen cecum and lateral tongue. Overall, the bundle remains approximately midway between these landmarks. Longer hyoid-to-mentum distance resulted in a slightly more medial NVB (longer lateral tongue margin-to-NVB transverse distance. A greater tongue depth (foramen cecum-to-hyoid distance) resulted in a more inferior NVB indicating that the bundle maintains a close relationship to the hyoid bone. TMN Staging and Definitions
Regional lymph nodes (N) Pathology / Differential Diagnosis SCC or one of its variants
accounts for 95% of malignant lesions found at the base of tongue. Lymphoepithelioma
and verrucous carcinoma occurs rarely. Malignant lymphomas account for
about 1% to 2% of the all base of tongue (BOT) malignancies. Minor salivary
gland malignancies, plasmacytoma, and other rare tumors comprise the
remainder. Lymphomas are usually large submucosal masses. Minor salivary
gland tumors are also usually submucosal in their early phase but more
discrete and firm than lymphomas. SCC of the BOT tends to early, silent, deep infiltration, and therefore, the extent of the tumor is often underestimated by clinical examination. Tumors originating in the base of tongue tend to remain there unless they begin in the peripheral margin. Tonsillar cancers tend to invade the BOT but the BOT cancers show little tendency to spread to the palatine tonsils. Vallecular lesions are often relatively exophytic and spread along the mucosa to the lingual surface of the epiglottis, laterally along the pharyngoepiglottic fold and then to the lateral pharyngeal wall and anterior wall of the pyriform sinus. The vallecular cancer may penetrate through the thin mucous membrane of the vallecula; tumor spread may be contained for a while by the hyoepiglottic ligament, but this thin, often incomplete structure is eventually breached and cancer enters the pre-epiglottic space. Occasionally, cancers within the tongue base may spread into the preepiglottic space entirely beneath intact mucosa. The best way to evaluate such spread is by computed tomography or magnetic resonance imaging. Lesions that begin on the lateral base of the tongue may invade the glossotonsillar sulcus. Anterior spread may continue forward into the floor of the mouth deep within the sublingual space and not be visible or palpable. Direct lateral growth allows tumor to escape into the neck, since there is no effective muscular barrier at this point. The mylohyoid muscle is an effective barrier for oral tongue lesions, but the mylohyoid terminates near the angle of the mandible. The base of tongue mass may grow inferiorly and laterally and become palpable below the angle of the mandible because of direct spread into the soft tissues of the deep neck. This spread may be indistinguishable from an involved lymph node. Sometimes, both direct spread and lymph nodes are both present. Once tumor spread into the soft tissues of the neck, it can surround and invade the stylopharyngeus, styloglossus, and stylohyoid muscles and spread either superiorly or inferiorly along these muscle groups to their origins and insertions. Continued posterolateral growth can occasionally encase the carotid artery. Lymphatic Spread Lymphatic spread tends to begin in the subdigastric nodes. Spread along the jugular chain to the midjugular and lower jugular nodes naturally follows. The submandibular nodes may become involved if tumor extends anteriorly into the oral tongue or if massive upper neck disease is present. Submental spread is rare. The posterior cervical nodes are involved often enough to be included in treatment plans. Advanced lesions may involve the retropharyngeal lymph nodes. About 75% of patients with SCC of BOT have clinically positive neck nodes at presentation; 30% have bilateral lymph nodes. The incidence of occult disease in clinically negative necks is reported at 22%, but the figure is undoubtedly low, considering the selection of smaller lesions for operation and the use of preoperative irradiation. The actual risk for occult disease is estimated to be 30% - 50%. Treatment On even a casual review of the literature, it becomes clear that no single therapeutic regimen offers a clear-cut superior survival over other regimens. Reports highlighting various therapeutic options exist, but do not contain reports presenting any valid comparative studies of therapeutic options. Surgery and radiation therapy, alone or combined, are the mainstays of treatment for oropharyngeal cancer. Although chemotherapy has been used in numerous clinical trials that combine it with surgery and radiation therapy, none have shown any long-term benefit in terms of survival. Three prospective clinical trials that evaluated induction chemotherapy before surgery and radiation therapy found no improvement in survival when compared to surgery and radiation therapy alone. The ultimate therapeutic
choice will depend on a careful review of each individual case, paying
attention to the staging of the neoplasm, the general physical condition
of the patient, the emotional status of the patient, the experience
of the treating team, and the available treatment facilities. Over the past several decades, there has been a trend away from radical procedures such as the jaw-neck resection to more conservative procedures that result in far better physiologic function. Jaw-sparing resections are often used today, and the need for total laryngectomy has decreased as a result of conservation surgical techniques. Another major trend has been the shift from preoperative to postoperative radiation therapy. Surgery Surgical resection for BOT lesions is best suited for well-lateralized lesions with minimal neck disease. An anterior lesions may be resected leaving the larynx intact, while a posterior lesion may require the addition of supraglottic laryngectomy. Surgical approaches can be categorized into two broad categories: transoral vs. transcervical Transoral Approach The transoral approach to the oropharynx involves resection of the tumor through the open mouth with no external incisions. It is used infrequently because of its limited exposure. On the other hand, it incurs little morbidity, and defects can be closed by primary suturing, left to heal by secondary intention, or covered with a split-thickness skin graft. The transoral approach is indicated for small, superficial lesions (stage I) of the upper or anterior sites of the oropharynx. Carcinoma in situ is an ideal case. However, these tumors represent a paucity of BOT cancers. Exophytic tumors are also better suited to this approach than ulcerative ones. Just as for any other type of approach, frozen section margins should be checked to ensure complete excision. The approach should not be used if a neck dissection is to be performed because draining lymphatic channels between the primary excision site and neck may be left unresected. Transcervical Approaches External surgical approaches to oropharyngeal cancers involve raising skin flaps and entering the pharynx through the neck. Most flaps begin in the region of the mastoid tip on the ipsilateral side and curve down and across the neck horizontally. An apron flap that extends across the midline and nearly up to the opposite mastoid tip produces the best cosmetic results and allows the surgeon to explore the contralateral side of the neck to look for occult metastatic disease. Elevation of this flap over the mandible with entry into the gingivobuccal sulcus permits even wider exposure, but has the disadvantage of cutting one or both mental nerves. A second type of flap design that provides excellent exposure involves bringing the horizontal skin incision up through the midline so that it crosses the chin and splits the lip. This incision can then be carried posteriorly in the gingivobuccal sulcus, creating a cheek flap. Alternately, the incision can proceed directly posteriorly through the midline of the mandible and into the floor of the mouth. Regardless of which flap is used, wide exposure of the tumor is key to successful extirpation. Transcervical approaches include : lateral pharyngotomy, midline labiomandibular glossotomy, mandibular swing approach , lingual-mandibular release, and even total laryngectomy. At least an ipsilateral neck dissection is indicated; however, with the high risk of bilateral neck disease even in a patient with no node involvement, this represents incomplete treatment. Finally, the surgeon has the difficulty of determining tumor extent at the time of excision. Post operative radiotherapy may have to be administered in any event for close margins or for fear of recurrence in the neck.
Oropharyngeal cancer has a high incidence of both clinically positive and occult lymph node metastases. In the base of tongue, clinically positive nodes occur in about 30% of early tumors and 75% of advanced tumors. Contralateral metastases are also prone to occur in cases that cross the midline. The options for treating cervical metastases are surgery, radiation, or both. External approaches to the oropharynx are usually combined with some type of neck dissection. Complications of Surgery Morbidity of surgical treatment can quite devastating. Mandibular complications are usually related either to a surgical osteotomy or to prior radiation. If a segmental resection of the mandible is performed, malocclusion and difficulty chewing are the chief problems. Patients who have poor dentition or periodontal disease frequently require a full-mouth extraction before any radiation therapy. Nasal regurgitation and hypernasal speech are common sequelae of surgical resections in the oropharynx. Patients are often at significant risk for aspiration, which may lead to pneumonia. A lymphatic spread tends
to begin in the subdigastric nodes. Spread along the jugular chain to
the midjugular and lower jugular nodes naturally follows. The submandibular
nodes may become involved if tumor extends anteriorly into the oral
tongue or if massive upper neck disease is present. Submental spread
is rare. The posterior cervical nodes are involved often enough to be
included in treatment plans. Advanced lesions may involve the retropharyngeal
lymph nodes. Swallowing dysfunction often
follows a large resection. Radiotherapy Irradiation of cancer of the tongue base is accomplished by parallel opposed external-beam portals, which also encompass the regional lymph nodes on both sides. The risk of lymph node metastases in both the upper and lower neck is significant, and the entire neck on both sides is routinely treated even when the neck is clinically free of disease. Recent improvements in XRT has increased survival rates from 25% - 40% (1960 - 1970) to almost 65% - 75%.
Case Presentation Mr. F.W. is a 58-year-old white male who presented to the VAMC clinic in July, 1997, complaining of a "lump in his throat" and mild dysphagia. There was no history of otalgia, odynophagia, hoarseness, trismus, or weight loss. The patient had a 1-2 pack per day history of cigarette use for 30 years, but he quit in 1983. Past medical history was significant for non-insulin-dependent diabetes mellitus. Physical examination was remarkable for 2 x 2 cm exophytic mass at the left base of tongue. Left cervical lymphadenopathy was palpable at level II, measuring 2.5 x 2 cm. Pan-endoscopy was performed and revealed a 2 cm x 2 cm mass at the left base of tongue, extending to the vallecula. Direct laryngoscopy demonstrated no lesions in the larynx or hypopharynx. Esophagoscopy revealed normal mucosa. Microscopic examination identified squamous cell carcinoma. Computed tomography (CT) of the neck showed no obliteration of pre-epiglottic fat, but did reveal a 2.5 x 2 cm left neck mass at level II . Chest x-ray (PA/LAT) and routine serologic studies (including CBC, coagulation studies, and liver function tests) were within normal limits. The patient's disease was staged as T2N2bM0 SCC L BOT. The patient's treatment plan was discussed at the VAMC's multidisciplinary Tumor Board and radiotherapy was recommended as a single treatment modality. The patient received 7000 cGy to the primary tumor and left neck mass and 5000 cGy to the lymphatics in the neck. On follow-up examination five months later, there was no evidence of disease at the base of tongue, but a persistent left neck mass, measuring 1 x 1 cm, was noted. CT scan of the neck confirmed resolution of the patient's primary tumor, but revealed a 1.5 x 1cm mass with a necrotic center in the jugulodigastric chain at level II. On December 12, 1997, the patient underwent left modified radical neck dissection, sparing CN XI. Examination of the specimen revealed hyperplasia and focal atypia but no evidence of malignancy. The patient had an uneventful post-operative recovery and was discharged home in good condition with close follow-up in the OTO/HNS clinic.
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©2001,
The Bobby R. Alford Department of Otorhinolaryngology and Communicative Sciences,
Baylor College of Medicine
One Baylor Plaza, NA102, Houston, TX 77030 oto@bcm.tmc.edu
URL: http://www.bcm.tmc.edu/oto (Modified: 10/17/01)
