oral tongue case

[Reaganite]

41 year old guy s/p hemiglossectomy with final path: 2cm SCC of the oral tongue. Depth of invasion 1.4cm. Margins >5mm. No LVSI or PNI. No neck dissection performed. Preop CT neck negative. Surgery was 2 months ago, and surgeon recommended against radiation referral. Only seeing him because med onc who patient was referred to curbsided me.

a. Send back for dissection.
b. Treat neck.
c. Treat neck + primary (Recent RTOG head and neck postop protocols including T2N0 oral cavity primaries with depth of invasion >5mm.)


Thoughts?

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[medgator]

Don't recall the paper but that depth of invasion is concerning for a recurrence in the neck. I think he should have gotten adjuvant treatment to neck (and primary by convention) if he didn't get a neck dissection upfront. 2 months might still be in the window to treat

 

[seper]

I'd treat neck (IB-IV) and spare primary.

 

[Burt Radnolds]

The depth of invasion is highly concerning. The neck needs addressed in some fashion, be it sentinal node biopsy, neck dissection, or radiotherapy. I definitely don't think you are outside the "window" for effectiveness of postoperative therapy (The data regarding a 6 week window is actually pretty weak, but I still try to avoid treatment delays as much as possible).

Regarding treatment of the primary, I think you could go either way. According to this MSKCC oral cavity nomogram,
http://skynet.ohsu.edu/nomograms/postrt/oral.html (don't worry its not the bad terminator producing skynet, but a kind beneficent cancer curing helper skynet) your benefit from RT in this case will be minimal if he's a true N0 (assuming neck is addressed in another way). However, oral tongue tumors tend to have a poorer prognosis and high recurrence rates, and the guy is very young.

 

[Neuronix]

Where on the tongue was it? I'm thinking bilateral necks must be addressed in most cases, preferably by surgery first then likely radiation. I asked the initial question because of the peculiar drainage of the tip of the tongue (particularly IA and IV in addition to IB-III). I'd recommend treating primary site also.

If you do sim or otherwise image this guy pay close attention. I drew a full set of contours once on a very similar case before I had a chance to ask the attending if those big IA nodes were just post-surgical/inflammatory or cancerous... They were pathological about 2 months after surgery and patient went for dissection.

 

[BobbyHeenan]

In taking into account a number of the depth of invasion papers, I think the data more strongly predicts likelihood of lymph node mets and helps guide management of the unaddressed neck, not necessarily likelihood of ultimate primary site or neck failure after the neck has been addressed. This is discussed pretty well in the NCCN principles of surgery section for oral cavity.

Thus, for this patient I would do the following:

- make it clear to tumor board and/or the patient/providers that the neck needs addressed. He has an oral tongue primary with a very deep depth of invasion, so I'd roughly estimate chance of occult positive lymph node at least 25%.
- Thus, I would send back for dissection. If a bunch of nodes are taken and all negative, I'd then observe
- If patient/surgeon refused dissection I would treat bilateral necks. I'd lean toward not treating the primary, but would have to think about that some more.

As mentioned above, even T2N0 oral cavity s/p resection and dissection are eligible for RTOG 0920 if they have > 0.5 cm DOI. However, a T2N0M0 with no LVSI or PNI with node negative (ie "no negative risk factors") per NCCN is rec'd observation and no XRT. With wide margins on the primary and a bunch of negative nodes, I'd probably observe. I think it's completely reasonable to treat though and lots of people would probably disagree with me.