CC
A 40-year-old edentulous male is referred by his general dentist for evaluation of a tongue mass. The patient states, “My tongue hurts.”
HPI
The patient was referred to an oral and maxillofacial surgeon for evaluation of an ulcerative tongue lesion. The patient first noticed the lesion 8 months ago, and only for the past 2 months has the pain become worse. His general dentist had noted a large ulcerative lesion involving the right posterior lateral tongue. An incisional biopsy of the tongue mass was performed, resulting in the diagnosis of a poorly differentiated, invasive squamous cell carcinoma (SCC).
PMHX/PDHX/medications/allergies/SH/FH
The patient has hypertension, gastroesophageal reflux disease, and high cholesterol. He is currently taking simvastatin, hydrochlorothiazide, and Pepcid OTC. The patient also has a 60-pack-year history of cigarette smoking and has indulged in alcohol regularly for more than 20 years (risk factors for oral cancer). The family history is noncontributory.
Examination
General. The patient is a slim, pleasant white male who appears his stated age.
Intraoral. The patient is edentulous and has a prominent ulceration at the right posterior lateral tongue that measures 3 cm in length and 2 cm in width. The red and white lesion is tender and has a necrotic center with firm, everted edges along its periphery ( Fig. 77.1 ). The tongue is freely mobile. There appears to be no extension into the floor of the mouth.
Neck. There is no palpable lymphadenopathy.
Flexible fiberoptic laryngoscopy. The lesion does not extend into the base of tongue; the bilateral tonsillar pillars, epiglottis, valleculae, arytenoids, piriform sinuses, and glottis are without obvious lesions.
Extremity. Peripheral pulses are 2+ for all extremities, and there is no cyanosis, clubbing, or edema. Bilateral modified Allen’s tests reveal good collateral circulation to the hands.
Modified Allen’s test is used to assess the circulatory blood flow of the hand. The main blood supply to the hand is via the ulnar and radial arteries. The ulnar artery supplies the superficial palmar branch, and the radial artery supplies the deep palmar branch. (Communication between the superficial and deep systems allows perfusion of the hand if there is interruption of one of the two main arteries to the hand, such as with the radial forearm free flap harvest.) Allen’s test determines the perfusion of the hand by simulating complete interruption of the radial artery. This is to ensure that the hand remains viable upon harvesting of the radial forearm free flap. The test is performed by elevating the intended hand and digitally occluding both the ulnar and the radial arteries. The patient is asked to clench and release a fist to cause blanching of the hand. Next, the pressure over the ulnar artery is released, and the capillary refill of the hand is evaluated. A wide range of values for hand reperfusion have been noted, ranging from 3 to 15 seconds. Additional techniques to qualify hand perfusion include the use of pulse oximetry (placed on the first finger) or Doppler assessment in conjunction with the modified Allen’s test. If hand perfusion is predominately based from the radial artery, use of the contralateral forearm or of an ulnar fasciocutaneous free flap should be considered.
Imaging
In general, if the patient has a normal result on the modified Allen’s test, no imaging is necessary before radial forearm free flap harvest.
The workup of SCC of the tongue includes at a minimum computed tomography (CT) scanning of the head and neck with intravenous contrast (for improved delineation of soft tissue) and a chest radiograph (see Chapter 72 ).
In the current patient, axial and coronal CT scans demonstrated a 3-cm × 2-cm × 1.5-cm mass with poorly defined margins in the area of the tongue. No cervical lymphadenopathy was noted. The results of the chest radiograph were within normal limits.
Labs
Routine laboratory studies, such as a complete blood count, electrolyte studies, and coagulation studies, may be obtained to establish a baseline preoperatively. Liver function tests are obtained as part of the complete metabolic panel and are important screening tests for liver metastasis.
Before major ablative surgery and reconstruction, several laboratory tests with implications for wound healing may be considered. In patients for whom malnutrition is suspected, a prealbumin level can be helpful in determining the need for preoperative nutritional support (e.g., percutaneous endoscopic gastrostomy tube). In patients with a history of thyroid dysfunction or radiation to the head and neck, a thyroid-stimulating hormone level with reflex thyroxine level should be obtained because hypothyroidism can have profound negative effects on wound healing. Patients with or at risk for diabetes should have their hemoglobin A1c evaluated, with optimization of glucose levels before surgery.
Patients with impaired functional status should have an electrocardiography and cardiac risk assessment, and an echocardiogram may be helpful in determining baseline cardiac function. Stress tests before nonelective surgery are controversial; although stress tests have a high negative predictive value for major cardiac adverse events, the positive predictive value is low, and the results are unlikely to change the perioperative management. Prophylactic coronary artery revascularization before noncardiac surgery has not improved short- or long-term survival in large randomized clinical trials. Furthermore, coronary stenting requires dual antiplatelet therapy (DAPT), and early discontinuation of DAPT greatly increases the risk of stent thrombosis and should be avoided if possible. In most cases, given the nonelective and time-sensitive nature of oral cancer treatment, extensive cardiac workup should not delay surgery and should be deferred if the results are not expected to change perioperative management.
For the current patient, the results of all the laboratory studies mentioned were within normal limits.
Assessment
cT2N0M0, stage II (greatest clinical tumor dimension is between 2 and 4 cm, depth of invasion >5 to <10 mm, with no regional nodal metastasis and no distant metastasis on clinical or radiologic investigation) SCC of the right lateral tongue.
Treatment
Primary surgery is generally accepted as the standard of care for patients with oral SCC. Primary radiation with or without chemotherapy has been used for organ preservation, but most reports suggest lower survival or increased adverse effects such as osteoradionecrosis. Most patients are managed surgically, with radiation with or without chemotherapy reserved for adjuvant therapy depending on the risk factors determined on the final pathologic assessment. Occasionally, patients who are not suitable candidates for surgery because of unresectable disease or medical comorbidities are considered for primary radiation therapy.
Access to the lesion is considered first. In the current patient, the resection can be completed via a transoral approach. For larger oral SCCs of the oral cavity, it is not uncommon to gain access via a lip split mandibulotomy or “pull-through” approach ( Fig. 77.2 ). Along with resection of the tumor, reconstruction of the defect is planned preoperatively.
The concept of the reconstructive ladder is useful to describe reconstructive methods in order of complexity; however, it is not used to determine the best method for reconstructing any particular defect. In cases in which the defect will be relatively small or scarring is not expected to cause substantial morbidity, less complex options such as secondary intention, primary closure, or local flaps can be considered. Larger defects that will impair form or function or those that result in communication between the mouth and the neck generally require more robust reconstructive methods such as pedicled regional flaps or microvascular free flaps. In the current patient, the surgical defect after resection would result in a significant loss of tissue because oncologic clearance generally incorporates at least a 1-cm margin. The reconstructive surgeon should also consider that intraoperative findings or frozen section results may lead to a more extensive resection.
With respect to tongue defects, reconstruction should consider preserving the patient’s functions of speech and swallow. The anterior tongue, and particularly the tongue tip, are critical for articulation and for propelling a food bolus posteriorly; the posterior tongue is largely involved with swallowing. Primary closure is an acceptable means of reconstruction if closure will not restrict tongue mobility (e.g., cases with minimal floor of mouth involvement). When a glossectomy leaves more than 33% to 50% of the tongue, emphasis should be placed on maintaining mobility of the remaining tongue through the use of a thin, pliable flap, such as a radial or an ulnar fasciocutaneous free flap. When the defect leaves less than 33% to 50% of the original tongue, reconstruction shifts to the restoration of bulk to direct secretions toward the oropharynx and to provide contact of the neotongue with the palate for deglutition. For greater tissue bulk, the anterior lateral thigh free flap is an effective choice for reconstruction.
The radial forearm fasciocutaneous flap is the soft tissue flap of choice for reconstructing small- to medium-sized oral and oropharyngeal defects. Based on the radial artery and cephalic vein or venae comitantes, it consists of thin, pliable skin and a very long pedicle, which make it well suited for use in the oral cavity. It can be designed to include tendons, muscle, or a segment of bone up to 12 cm in length, making it also useful for composite maxillary and mandibular defects.
For the current patient, the radial forearm free flap was selected to provide bulk and to prevent restriction in tongue mobility that would affect speech and swallowing functions. The patient was placed under general anesthesia and underwent a tracheostomy to secure his airway. A marking pen was used to delineate the planned resection edges, and a paper template was used to approximate the size and shape of the resection. A right hemiglossectomy was performed, and the margins of the resection were confirmed to be adequate with frozen sections ( Fig. 77.3 A and B).
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