CC
A 55-year-old African American male presents to your office and states, “There is something wrong with my tongue, and my dentist said I need to have it checked.” (African Americans have a higher incidence of squamous cell carcinoma [SCC] and double the mortality rates.)
HPI
The patient recently visited his general dentist for evaluation of his ill-fitting upper dentures. Upon examination, a red and white, fungating, nontender, ulcerated mass of the right lateral border of his tongue was noted (SCC until proved otherwise). The patient was otherwise asymptomatic. (Early mucosal lesions of oral cancer are usually asymptomatic; painful ulcers are more suggestive of an inflammatory or infectious cause.) Within 2 weeks, he had an incisional biopsy of the lesion by a local oral surgeon, with a subsequent diagnosis of an invasive SCC.
The biopsy report from the previous surgeon was requested and reviewed. (It is important to confirm the diagnosis before definitive treatment.) The histopathology report described a loss of normal maturation of the epithelial cells, with invasion of abnormal cells beyond the basement membrane into the underlying subcutaneous tissues and muscle layers (indicative of invasive tumor). Stranding and islands of keratin-like material are also noted. (Keratin is indicative of greater cellular differentiation.) The abnormal cells appeared pleomorphic (having many different shapes) with an increased nuclear-to-cytoplasmic ratio and occasional mitotic figures (signs of cellular malignant transformation). Generalized inflammatory infiltration was noted at the deepest portion of the specimen. The diagnosis of a grade III (see Discussion) invasive SCC was made.
PMHX/PDHX/medications/allergies/SH/FH
The patient has a 45-pack-year history of tobacco use. In addition, he regularly consumes alcoholic beverages on weekends and occasionally on weekdays. (Tobacco and alcohol are both risk factors for the development of oral SCC; see Discussion.) He does not receive routine medical or dental treatment. (Lack of routine health care can delay early detection of oral SCC.)
The strong association between SCC and tobacco use is well established. The risk of SCC developing in a smoker is approximately five to nine times greater than in a nonsmoker. It is also postulated that smoking is responsible for approximately 90% of oral cavity tumors in males and 61% of those in females. Chewing tobacco is associated with an increased risk of oral SCC. Alcohol use alone and in conjunction with tobacco use has been shown to pose an increased risk of oral SCC. In studies controlled for smoking, those who consumed moderate to heavy amounts of alcohol were found to have a three to nine times greater risk of the development of SCC. When alcohol and smoking are combined, alcohol is considered to be a promoter and a possible co-carcinogen to tobacco, with some studies showing a 100-fold increased risk.
Examination
The examination of a patient with the diagnosis of SCC should entail a complete head and neck examination to search for neck metastasis (the most common areas of distant metastasis are the lungs); synchronous primary tumors; or in cases of presenting neck disease, occult primary tumors. Particular attention is given to the status of the lymph nodes and the size of the presenting lesion. Previous studies have shown that on initial examination of a known primary tumor, there is a 3% to 7% incidence of a synchronous tumor in the upper aerodigestive tract. A nasopharyngolaryngoscopic (NPL) examination is indicated to evaluate the subepiglottic and supraepiglottic regions, posterior oropharynx, larynx, and nasopharynx.
General. The patient is a well-developed and well-nourished African American male who appears his stated age, with no signs of cachexia (seen with advanced disease).
Maxillofacial. There is a 3.5-cm red and white, fungating mass on the right lateral border of the tongue with central ulceration. (A nonhealing ulcer in the oral cavity is considered to be SCC until proved otherwise; Fig. 72.1 .) There is no pain or bleeding noted on palpation of the lesion. (Although ulcers from SCC may occasionally bleed, they are usually painless.) Some patients may also complain of ear pain if the lesions are deep and involve the lingual nerve. When ear pain is present, perineural invasion cannot be ruled out until final pathology. Examination of the remaining oral cavity, including the buccal mucosa, hard and soft palate, parotid and submandibular glands, oropharynx, and nasopharynx, reveals no other abnormalities. Nasopharyngolaryngoscopy reveals no abnormal tissues in the posterior oropharynx, subglottic or supraglottic regions, or nasopharynx. (NPL should be performed as part of the head and neck evaluation of tongue SCC.)
Neck. No cervical or submandibular lymphadenopathy is noted. (Cancers of the tongue usually metastasize to the level I and II nodes.) There is no pain on palpation of the neck. (Lymphadenopathy from cancer is usually painless.)
The presence of occult neck disease in the N0 neck is related to the tumor’s stage, size, and depth of invasion; perineural invasion; and histologic grade. Lesions larger than 4 mm in depth, along with a high-grade histology, have a greater than 20% risk of neck disease in the N0 neck.
Imaging
The initial imaging modalities for the evaluation of patients with SCC begin with a panoramic radiograph. This is a useful screening tool to evaluate for the presence of bony infiltration associated with the tumor. It also provides valuable information regarding the long-term prognosis of the remaining dentition because some patients may require extraction of carious or periodontally involved teeth before radiotherapy.
A computed tomography (CT) scan of the head and neck is the commonly used imaging study of choice to delineate the lesion and assess the neck for cervical lymphadenopathy. (Nodes larger than 1.5 cm, with central necrosis, an ovoid shape, and fat stranding are indicative of nodal metastasis.) Additional tests, such as magnetic resonance imaging and ultrasonography, can be used to assess the status of the cervical nodes.
Anteroposterior and lateral chest radiographs are used to screen for underlying pulmonary disease and evaluate for pulmonary metastasis because the lungs are the most common areas of metastasis for this tumor. Positron emission tomography (PET) scans are becoming a common modality for the evaluation of distant metastasis. This technology uses an 18F-fluorodeoxyglucose (FDG) marker to examine sites of increased glucose uptake, which are seen with metabolically active cancer cells. This imaging modality is commonly used to rule out distant disease, and it is also helpful for clinically staging the tumor. Several studies have demonstrated that a standardized uptake value (SUV) of greater than 3 correlates with hypermetabolism suggestive of a pathologic process. Clinical staging is helpful because a treatment plan can be worked up for the patient and adjuvant modalities recommended.
In the current patient, axial and coronal CT images of the head and neck, with and without contrast, revealed a 3.5-cm, well-circumscribed lesion of the right lateral border of the tongue musculature. No evidence of cervical lymphadenopathy was noted. The PET scan performed with 18F-FDG showed a hypermetabolic area in the right tongue coinciding with the clinical lesion. No other abnormal uptake in the neck or chest was noted. The panoramic and chest radiographs revealed no abnormalities.
Labs
A complete metabolic panel (CMP), complete blood count (CBC), and coagulation profile (prothrombin time [PT], partial thromboplastin time, and international normalized ratio) are mandatory laboratory studies in the patients with cancer because of metabolic, electrolyte, and nutritional derangements that may accompany malignant disease. Liver function tests are obtained as part of the CMP and are important screening tests for liver metastasis or alcohol dependence. Other laboratory studies can be ordered based on the patient’s medical history.
In the current patient, the CBC, CMP, liver function test results, and coagulation studies were within normal limits.
Assessment
T2, N0, M0 (tumor >2 cm but <4 cm, with no positive nodes and no distant metastasis) stage II, oral SCC of the right lateral border of the tongue with a Broders’ histologic grade of III.
Treatment
Treatment of patients with SCC of the tongue begins with a complete history and physical examination, including NPL. This is followed by appropriate tests, including CBC with differentials, electrolytes, liver function tests, chest radiographs, and CT with contrast. The role of PET scanning for occult metastasis continues to evolve.
The treatment of SCC is site specific; surgical ablation with minimum 1.0- to 1.5-cm margins is the main modality of treatment ( Fig. 72.2 ). Most oral cavity tumors are approached transorally; however, some tumors may need to be accessed via a transfacial or transcervical approach. Sometimes when the tumor is located in the dentoalveolar process of the mandible, the inferior border can be preserved (marginal mandibulectomy), depending on the degree of infiltration. However, when the cancellous portion of the mandible is invaded, segmental resection is required to maintain oncologic safety.
A common procedure that accompanies the removal of the tumor is the removal of the fibrofatty contents of the neck, for treatment of cervical lymphatic metastases and for complete staging of the cancerous process (see the section on neck dissections later in this chapter).
Reconstruction and rehabilitation. Depending on the defect, the reconstructive surgery can be divided into soft tissue or bony reconstruction (or both). Closing the defect primarily is ideal if it can be accomplished. Soft tissue surgical procedures include closure by secondary intention, skin grafts, local flaps, or microvascular free flaps. Simultaneous bony reconstruction can be accomplished using vascularized free flaps from the iliac crest, scapula, or fibula when needed. In select cases for SCC involving the maxilla, an obturator can provide temporary or definitive rehabilitation for the ablative defect depending on the patient’s wishes. When large ablative and reconstructive procedures are performed, they can be performed simultaneously (see Chapter 12 ). Depending on the amount of healing and dysfunction anticipated, a percutaneous endoscopic gastrostomy tube and elective tracheostomy can be performed to secure the airway and aid in the nutritional support of the patient during the postoperative period.
Radiation therapy. Radiation therapy can be used as a primary or an adjuvant therapy. Primary radiotherapy is usually reserved for patients with significant comorbidities or when the primary tumor or the patient is not amenable to surgery. This is not a primary indication for early-stage SCC because of the associated morbidity, including dysphagia and xerostomia. Another significant risk is the development of metachronous lesions after radiation therapy.
Postoperative radiation therapy is commonly used as a part of the comprehensive treatment. The indications for its use include positive or near margins, significant perineural or perivascular invasion, bone involvement, multiple nodal involvement, extracapsular spread, or stage III or stage IV disease. Typically, about 6000 cGy in divided doses is administered, and treatment is initiated soon after healing from the initial surgery is complete. Surgery combined with radiation therapy and chemotherapy has increased the 5-year survival rates for stage III and stage IV cancers by 10%.
In the current patient, a right partial glossectomy via a transoral approach was performed with 1.5-cm margins. The status of the margins was evaluated using frozen section microscopy, which demonstrated negative margins. An ipsilateral supraomohyoid neck dissection (levels I–III) was completed for staging, which revealed no positive lymph nodes. The tongue defect was reconstructed with a radial forearm free flap, anastomosing with the facial artery and vein. An elective tracheostomy was performed. After complete healing, the patient was followed closely for signs of recurrence. (A total of 85% of recurrences occur in the first 3 years after initial treatment.)
Occasionally, a cancerous lesion can present within 1 cm of midline or at the midline, which can drain to ipsilateral or contralateral lymph node groups (or both groups) ( Fig. 72.3 ). This is of great importance when planning for elective neck dissection to determine pathological staging of neck disease. In this clinical situation, the possibility of bilateral neck dissection should be discussed with the patient well in advance ( Fig. 72.4 ).
