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The predominant therapy for tongue cancer is surgical resection. Adjunctive chemotherapy, radiation, chemoradiation, or brachytherapy may be required.<ref name="pmid16168836">{{cite journal| author=Bourgier C, Coche-Déquéant B, Fournier C, Castelain B, Prévost B, Lefebvre JL et al.| title=Exclusive low-dose-rate brachytherapy in 279 patients with T2N0 mobile tongue carcinoma. | journal=Int J Radiat Oncol Biol Phys | year= 2005 | volume= 63 | issue= 2 | pages= 434-40 | pmid=16168836 | doi=10.1016/j.ijrobp.2005.02.014 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16168836  }} </ref><ref name="pmid2807886">{{cite journal| author=McGregor AD, MacDonald DG| title=Patterns of spread of squamous cell carcinoma within the mandible. | journal=Head Neck | year= 1989 | volume= 11 | issue= 5 | pages= 457-61 | pmid=2807886 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2807886  }} </ref><ref name="pmid3220769">{{cite journal| author=McGregor AD, MacDonald DG| title=Routes of entry of squamous cell carcinoma to the mandible. | journal=Head Neck Surg | year= 1988 | volume= 10 | issue= 5 | pages= 294-301 | pmid=3220769 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3220769  }} </ref><ref name="pmid2370178">{{cite journal| author=Wendt CD, Peters LJ, Delclos L, Ang KK, Morrison WH, Maor MH et al.| title=Primary radiotherapy in the treatment of stage I and II oral tongue cancers: importance of the proportion of therapy delivered with interstitial therapy. | journal=Int J Radiat Oncol Biol Phys | year= 1990 | volume= 18 | issue= 6 | pages= 1287-92 | pmid=2370178 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2370178  }} </ref>  
The predominant therapy for tongue cancer is surgical resection. Adjunctive chemotherapy, radiation, chemoradiation, or brachytherapy may be required.<ref name="pmid16168836">{{cite journal| author=Bourgier C, Coche-Déquéant B, Fournier C, Castelain B, Prévost B, Lefebvre JL et al.| title=Exclusive low-dose-rate brachytherapy in 279 patients with T2N0 mobile tongue carcinoma. | journal=Int J Radiat Oncol Biol Phys | year= 2005 | volume= 63 | issue= 2 | pages= 434-40 | pmid=16168836 | doi=10.1016/j.ijrobp.2005.02.014 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16168836  }} </ref><ref name="pmid2807886">{{cite journal| author=McGregor AD, MacDonald DG| title=Patterns of spread of squamous cell carcinoma within the mandible. | journal=Head Neck | year= 1989 | volume= 11 | issue= 5 | pages= 457-61 | pmid=2807886 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2807886  }} </ref><ref name="pmid3220769">{{cite journal| author=McGregor AD, MacDonald DG| title=Routes of entry of squamous cell carcinoma to the mandible. | journal=Head Neck Surg | year= 1988 | volume= 10 | issue= 5 | pages= 294-301 | pmid=3220769 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3220769  }} </ref><ref name="pmid2370178">{{cite journal| author=Wendt CD, Peters LJ, Delclos L, Ang KK, Morrison WH, Maor MH et al.| title=Primary radiotherapy in the treatment of stage I and II oral tongue cancers: importance of the proportion of therapy delivered with interstitial therapy. | journal=Int J Radiat Oncol Biol Phys | year= 1990 | volume= 18 | issue= 6 | pages= 1287-92 | pmid=2370178 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2370178  }} </ref>  


==Medical Therapy==
==Radiation therapy==
*Superficial lesions of tongue cancer are treated with single-modality therapy (eg, radiation or surgery)
* Radiation therapy may be used as a treatment modality for small or superficial tongue lesions.
*Large lesions are treated with multiple modalities (eg, combined surgery and radiation).
 
*Cervical nodes are treated with either surgery or radiation therapy.
*Because of the side effects of radiotherapy, younger patients are treated surgically.
*A modality that preserves greatest function but places the patient at a greatest risk of local or regional recurrence should not be used.
*Surgery or radiation therapy may be chosen in older patients.
*In younger patients tongue cancer is treated surgically to avoid radiation therapy because of the adverse affects of radiation. Premature use of radiation therapy eliminates it from future consideration if the disease recurs. In an older patient, either surgery or radiation therapy may be chosen if the lesion is superficial and small.  
*Large lesions are treated with combined surgery and radiation.  
===Radiation therapy===
=====Adjuvant theapy indications<ref name="pmid23184439">{{cite journal| author=Ganly I, Goldstein D, Carlson DL, Patel SG, O'Sullivan B, Lee N et al.| title=Long-term regional control and survival in patients with "low-risk," early stage oral tongue cancer managed by partial glossectomy and neck dissection without postoperative radiation: the importance of tumor thickness. | journal=Cancer | year= 2013 | volume= 119 | issue= 6 | pages= 1168-76 | pmid=23184439 | doi=10.1002/cncr.27872 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23184439 }}</ref>=====
*Radiation therapy may be used as a treatment modality for small or superficial tongue lesions.
* Patients who have positive resection margins
*Adjuvant postoperative radiation to the primary site is indicated for:  
* Patients who have positive or close final resection margins
* Patients with bone invasion  
* Patients with bone invasion  
* Patients with positive lymph nodes
* Patients with positive lymph nodes
* Postoperative radiation therapy should be considered for depth of invasion and for tumor thickness >4 mm, even in the setting of a negative unilateral neck dissection[68]
* Tumor thickness >4 mm
* Patients with regional recurrence[69]
* Patients with regional recurrence
* In patients who refuse surgery or those who are poor surgical candidates radiation therapy is considered for the primary management of small oral tongue cancers.
 
The three main techniques of radiation therapy administration includes the following:
===== Techniques of radiation therapy =====
*External beam radiotherapy
*External beam radiotherapy
**Depending on tumor size and location, nodal status, and the possible inclusion of interstitial implants, external beam radiotherapy using a single ipsilateral portal or bilateral-opposed portals may be selected.<ref name="pmid16168836">{{cite journal| author=Bourgier C, Coche-Déquéant B, Fournier C, Castelain B, Prévost B, Lefebvre JL et al.| title=Exclusive low-dose-rate brachytherapy in 279 patients with T2N0 mobile tongue carcinoma. | journal=Int J Radiat Oncol Biol Phys | year= 2005 | volume= 63 | issue= 2 | pages= 434-40 | pmid=16168836 | doi=10.1016/j.ijrobp.2005.02.014 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16168836  }} </ref>
**Depending on tumor size and location, nodal status, and the possible inclusion of interstitial implants, external beam radiotherapy using a single ipsilateral portal or bilateral-opposed portals may be selected.<ref name="pmid16168836">{{cite journal| author=Bourgier C, Coche-Déquéant B, Fournier C, Castelain B, Prévost B, Lefebvre JL et al.| title=Exclusive low-dose-rate brachytherapy in 279 patients with T2N0 mobile tongue carcinoma. | journal=Int J Radiat Oncol Biol Phys | year= 2005 | volume= 63 | issue= 2 | pages= 434-40 | pmid=16168836 | doi=10.1016/j.ijrobp.2005.02.014 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16168836  }} </ref>
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==== '''Non-surgical candidates''' ====
==== '''Non-surgical candidates''' ====
** Functional organ preservation approaches are widely used for patients with locoregionally advanced oropharyngeal, hypopharyngeal, and laryngeal cancers. However, this approach has not been widely applied to patients with oral cavity cancer. Data are more limited, there are concerns about increased toxicity [12], and no survival advantage has been demonstrated for patients with stage III or IV primary tumors of the oral cavity [9,11,13].
* For patients who are not surgical candidates but can tolerate chemotherapy, a combined chemotherapy and radiotherapy is appropriate.<ref name="pmid12525526">{{cite journal| author=Licitra L, Grandi C, Guzzo M, Mariani L, Lo Vullo S, Valvo F et al.| title=Primary chemotherapy in resectable oral cavity squamous cell cancer: a randomized controlled trial. | journal=J Clin Oncol | year= 2003 | volume= 21 | issue= 2 | pages= 327-33 | pmid=12525526 | doi=10.1200/JCO.2003.06.146 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12525526  }}</ref>
** Initial RT and/or chemotherapy is an alternative for patients who refuse surgery, have a technically unresectable tumor (carotid artery encasement, vertebral or brain invasion), would have an unacceptable functional outcome with surgery, or are medically inoperable.
* For patients who are not surgical candidates with bad medical condition and can not tolerate the chemotherapy, radiotheapy without chemotherapy is more appropriate.<ref name="pmid19856305">{{cite journal| author=Stenson KM, Kunnavakkam R, Cohen EE, Portugal LD, Blair E, Haraf DJ et al.| title=Chemoradiation for patients with advanced oral cavity cancer. | journal=Laryngoscope | year= 2010 | volume= 120 | issue= 1 | pages= 93-9 | pmid=19856305 | doi=10.1002/lary.20716 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19856305  }}</ref>
** A combined modality approach utilizing both chemotherapy and RT is appropriate for patients who are not surgical candidates but whose overall condition will tolerate the potential increase in toxicity. Approaches that may be used include induction chemotherapy followed by definitive concurrent chemoradiotherapy or RT and immediate concurrent chemoradiotherapy
* For patients with non-operable tumors and failed medical trials, complete resection may be indicated as a salvage procedure.
** RT without chemotherapy is appropriate for patients who are not surgical candidates and whose medical condition will not tolerate the increased toxicity associated with chemotherapy or concurrent chemoradiotherapy.
* For patients with stage III or IV primary tumors, survival rates do not show improvement.
** For patients where a nonsurgical approach was originally undertaken because of either the low probability of surgical cure or the morbidity associated with resection, complete resection may be indicated as a salvage procedure for residual disease.


===Chemotherapy===
==Chemotherapy==
*Chemotherapy is used in patients who present with extensive primary lesions, in patients with distant metastasis or with poor prognosis.
*Early tumors are not treated with chemotherapy because of the high success of either radiation therapy or surgery.  
*Early tumors are not treated with chemotherapy because of the high success of either radiation therapy or surgery.  
*Chemotherapy is used in patients who present with extensive primary lesions, in patients with distant metastasis or with poor prognosis.
*The factors to be considered if chemotherapy is being contemplated includes the following:
*The factors to be considered if chemotherapy is being contemplated includes the following:
**Stage of disease
**Stage of disease
Line 47: Line 44:
**Tolerance to adverse effects
**Tolerance to adverse effects


* There is no evidence to support the use of chemotherapy for early stage oral cavity cancer. [70
* There is no evidence to support the use of chemotherapy for early stage oral cavity cancer.<ref name="pmid18707827">{{cite journal| author=Gomez DR, Zhung JE, Gomez J, Chan K, Wu AJ, Wolden SL et al.| title=Intensity-modulated radiotherapy in postoperative treatment of oral cavity cancers. | journal=Int J Radiat Oncol Biol Phys | year= 2009 | volume= 73 | issue= 4 | pages= 1096-103 | pmid=18707827 | doi=10.1016/j.ijrobp.2008.05.024 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18707827  }}</ref>


===Targeted therapy===
===Targeted therapy===

Revision as of 16:04, 29 November 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Simrat Sarai, M.D. [2]

Overview

The predominant therapy for tongue cancer is surgical resection. Adjunctive chemotherapy, radiation, chemoradiation, or brachytherapy may be required.[1][2][3][4]

Radiation therapy

  • Radiation therapy may be used as a treatment modality for small or superficial tongue lesions.
  • Because of the side effects of radiotherapy, younger patients are treated surgically.
  • Surgery or radiation therapy may be chosen in older patients.
  • Large lesions are treated with combined surgery and radiation.
Adjuvant theapy indications[5]
  • Patients who have positive resection margins
  • Patients with bone invasion
  • Patients with positive lymph nodes
  • Tumor thickness >4 mm
  • Patients with regional recurrence
Techniques of radiation therapy
  • External beam radiotherapy
    • Depending on tumor size and location, nodal status, and the possible inclusion of interstitial implants, external beam radiotherapy using a single ipsilateral portal or bilateral-opposed portals may be selected.[1]
  • Brachytherapy
    • Brachytherapy may be used as a single modality or can be used following partial glossectomy. Most often brachytherapy is used after the tumor bed has been preliminarily treated with external beam radiotherapy. It may result in tongue edema, necessitating an elective tracheostomy.[2][3]
  • Orthovoltage radiotherapy
    • In patients with well-marginated and exophytic lesions, prior to external beam radiation therapy cone therapy is administered. An intraoral cone is placed against the tumor bed and either electrons or orthovoltage may be given with equal control rates.
    • For tumors less than 2 cm thick, radiotherapy of oral tongue cancer typically combines external beam radiotherapy with an intraoral cone.
    • For tumors less than 2 cm thick, radiotherapy combines external beam radiotherapy with an interstitial brachytherapy.
    • Small lesions less than or equal to 10 mm and superficial lesions can be treated with either an intraoral cone or interstitial brachytherapy alone.[4]

Non-surgical candidates

  • For patients who are not surgical candidates but can tolerate chemotherapy, a combined chemotherapy and radiotherapy is appropriate.[6]
  • For patients who are not surgical candidates with bad medical condition and can not tolerate the chemotherapy, radiotheapy without chemotherapy is more appropriate.[7]
  • For patients with non-operable tumors and failed medical trials, complete resection may be indicated as a salvage procedure.
  • For patients with stage III or IV primary tumors, survival rates do not show improvement.

Chemotherapy

  • Chemotherapy is used in patients who present with extensive primary lesions, in patients with distant metastasis or with poor prognosis.
  • Early tumors are not treated with chemotherapy because of the high success of either radiation therapy or surgery.
  • The factors to be considered if chemotherapy is being contemplated includes the following:
    • Stage of disease
    • General medical status
    • Potential efficacy
    • Tolerance to adverse effects
  • There is no evidence to support the use of chemotherapy for early stage oral cavity cancer.[8]

Targeted therapy

Targeted therapy may be used in combination with chemotherapy or radiation therapy. Targeted therapy drugs, such as monoclonal antibodies, interrupt the spread and growth of specific tongue cancer cells.

References

  1. ↑ 1.0 1.1 Bourgier C, Coche-Déquéant B, Fournier C, Castelain B, Prévost B, Lefebvre JL; et al. (2005). "Exclusive low-dose-rate brachytherapy in 279 patients with T2N0 mobile tongue carcinoma". Int J Radiat Oncol Biol Phys. 63 (2): 434–40. doi:10.1016/j.ijrobp.2005.02.014. PMID 16168836.
  2. ↑ 2.0 2.1 McGregor AD, MacDonald DG (1989). "Patterns of spread of squamous cell carcinoma within the mandible". Head Neck. 11 (5): 457–61. PMID 2807886.
  3. ↑ 3.0 3.1 McGregor AD, MacDonald DG (1988). "Routes of entry of squamous cell carcinoma to the mandible". Head Neck Surg. 10 (5): 294–301. PMID 3220769.
  4. ↑ 4.0 4.1 Wendt CD, Peters LJ, Delclos L, Ang KK, Morrison WH, Maor MH; et al. (1990). "Primary radiotherapy in the treatment of stage I and II oral tongue cancers: importance of the proportion of therapy delivered with interstitial therapy". Int J Radiat Oncol Biol Phys. 18 (6): 1287–92. PMID 2370178.
  5. ↑ Ganly I, Goldstein D, Carlson DL, Patel SG, O'Sullivan B, Lee N; et al. (2013). "Long-term regional control and survival in patients with "low-risk," early stage oral tongue cancer managed by partial glossectomy and neck dissection without postoperative radiation: the importance of tumor thickness". Cancer. 119 (6): 1168–76. doi:10.1002/cncr.27872. PMID 23184439.
  6. ↑ Licitra L, Grandi C, Guzzo M, Mariani L, Lo Vullo S, Valvo F; et al. (2003). "Primary chemotherapy in resectable oral cavity squamous cell cancer: a randomized controlled trial". J Clin Oncol. 21 (2): 327–33. doi:10.1200/JCO.2003.06.146. PMID 12525526.
  7. ↑ Stenson KM, Kunnavakkam R, Cohen EE, Portugal LD, Blair E, Haraf DJ; et al. (2010). "Chemoradiation for patients with advanced oral cavity cancer". Laryngoscope. 120 (1): 93–9. doi:10.1002/lary.20716. PMID 19856305.
  8. ↑ Gomez DR, Zhung JE, Gomez J, Chan K, Wu AJ, Wolden SL; et al. (2009). "Intensity-modulated radiotherapy in postoperative treatment of oral cavity cancers". Int J Radiat Oncol Biol Phys. 73 (4): 1096–103. doi:10.1016/j.ijrobp.2008.05.024. PMID 18707827.

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