Tongue cancer medical therapy

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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.

Medical Therapy

• Superficial lesions of tongue cancer are treated with single-modality therapy (eg, radiation or surgery)
• Large lesions are treated with multiple modalities (eg, combined surgery and radiation).
• Cervical nodes are treated with either surgery or radiation therapy.
• A modality that preserves greatest function but places the patient at a greatest risk of local or regional recurrence should not be used.
• 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.

The therapeutic decision must take into consideration the following factors:

• Patient's age
• Lifestyle
• Willingness to participate in the therapeutic regimen.

ADJUVANT THERAPY 

Adjuvant postoperative radiation to the primary site and unilateral or bilateral neck, with or without concurrent chemotherapy, is indicated for patients who have positive or close final resection margins (if not reresected), bone invasion, and for most patients with pathologically 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. In a retrospective study of 164 "low-risk" early stage oral tongue cancer patients treated with surgery alone and then observed, the regional recurrence rate was 24 percent for tumors ≥4 mm [68].

Of the patients with regional recurrence, 39 percent occurred in the contralateral neck, suggesting the need for careful consideration of bilateral neck irradiation if used, particularly for primary tumors that approach or involve the midline. PORT should also be considered if there is lymphovascular or perineural invasion in the primary tumor [69].

 [70].There is no evidence to support the use of chemotherapy for early stage oral cavity cancer.

Nonsurgical 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].

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.

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

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 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.

Radiation therapy

• Radiation therapy may be used as a treatment modality for small or superficial tongue lesions.
• For T1 and T2 oral tongue cancers the local control rates are similar for surgery and radiation therapy. However, radiation therapy has the benefit of preserving tongue function and normal anatomy.
• In early or moderately advanced tumors such as T1, T2, early T3, postoperative radiation therapy is considered if adverse histological features are noted in the pathology specimen of the primary tumor or the specimen from elective neck disection.
• 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.
• For advanced lesions, combined treatment with surgery is given. The majority of patients initially undergo surgical resection; however, many patients have recently been treated with high-dose preoperative radiation therapy with either external radiation therapy plus interstitial radiotherapy with or external beam radiotherapy alone followed by surgical resection of the residual tumor. The latter technique results in a less-extensive tongue resection, without compromising the prognosis.

The three main techniques of radiation therapy administration includes the following:

• 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.
• 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.
• 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.

Chemotherapy

• 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:
  • Stage of disease
  • General medical status
  • Potential efficacy
  • Tolerance to adverse effects

Chemoradiation

With chemoradiation, chemotherapy is administered at the same time as radiation therapy. The benefits of chemoradiation includes the following:

• Synergism
• Radiosensitization
• Beneficial antiproliferative effects
• Improved locoregional control
• Improved survival

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.