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Malignant Tumors of the Base of Tongue Treatment & Management

  • Author: Talib Najjar, DMD, MDS, PhD; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: Jul 30, 2015
 

Medical Therapy

Treatment for patients with malignant neoplasms of the base of the tongue depends on various factors. These factors include the clinical stage, histology, age, associated medical conditions, patient compliance, and potential adverse effects, complications, and outcomes. In order to allow the patient to make a reasonable and informed decision regarding treatment options, discuss these factors in detail before treatment.

Nonsurgical therapy for malignant neoplasms of the base of the tongue has garnered long-standing interest because of the significant potential morbidity associated with surgical resection. Historically, chemotherapy for squamous cell carcinoma of the head and neck has had limited success. Increased efficacy with platinum-based drugs and newer drug regimens has been demonstrated in the last 20 years. Typically, these clinical protocols include radiotherapy as a major component of the treatment plan. Curative chemotherapy given as single-modality treatment for squamous cell carcinoma of the base of tongue, regardless of clinical stage, is uncommon and is not recommended at present.

As is true with other sites of the head and neck, early-stage mucosal squamous cell carcinomas can be treated adequately with radiotherapy or surgical resection. With increasing tumor stage, cure rates decrease significantly regardless of treatment. Chemoradiation protocols are generally associated with significant morbidity in terms of speech and swallowing which tend to improve over time. Tumor stage, overall treatment time, overall stage, and the addition of a neck dissection significantly influence locoregional control.

Base of tongue carcinomas can be managed with primary chemoradiotherapy, with elective planned neck dissection for patients with palpable lymph node metastases. Brachytherapy boost (20-30 Gy) to the base of the tongue has been used in the past but has largely been replaced by three dimensional radiotherapy treatment planning. Patients usually require gastrostomy and occasional tracheostomy. The addition of epidermal growth factor receptor (EGFR) inhibitors, including the monoclonal antibody (MAb) cetuximab, has show efficacy in the treatment of primary and recurrent squamous cell carcinomas of the head and neck. They may be promising modes of therapy for base of the tongue carcinoma in the future.

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Surgical Therapy

Cancer of the base of the tongue have traditionally been removed by resecting the mandible or by using a translabial transmandibular approach. These procedures involve significant morbidity, including lip and chin scars, malocclusion, compromised deglutition, chronic aspiration, and altered speech articulation. Therefore, alternative techniques have been described to minimize the morbidity associated with transmandibular tongue resection.

As compared with transmandibular resection of tumors, transpharyngeal approaches show no measurable difference in terms of survival, tumor-free margins, speech, or swallowing; furthermore, transpharyngeal approaches result in less aspiration than transmandibular resection.

Many clinicians manage this disease with combined partial glossectomy (with attempts to avoid laryngectomy if possible) with planned postoperative radiotherapy. The risk of aspiration is higher for older patients with large primary tumors, and total laryngectomy is sometimes required. Recent advances in the application of minimally invasive technologies to cancers of the base of tongue have resulted in similar locoregional control rates with the decreased morbidity of larger, open procedures.

Good locoregional control rates have been reported at the expense of functional outcome. In general, surgery with radiotherapy is associated with better survival and less locoregional failure but more systemic failure than nonoperative methods of treatment. Positive margins are associated with a higher local failure rate. The placement of permanent gastrostomy tubes and/or the performance of tracheostomy to prevent aspiration are not uncommon. Planned postoperative chemoradiotherapy is indicated for advanced disease.

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Follow-up

Postoperative patients are monitored monthly for the first 12-18 months following therapy. Follow-up diagnostic imaging studies are recommended in the first 6 months, particularly in patients who undergo nonsurgical treatment.

For excellent patient education resources, visit eMedicineHealth's Cancer Center. Also, see eMedicineHealth's patient education article Cancer of the Mouth and Throat.

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Complications

Treatment complications include chronic dysphagia, sepsis, anemia, fistula, osteoradionecrosis, aspiration, and even death.

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Outcome and Prognosis

Historically, patients with advanced-stage disease have been treated with surgical resection and postoperative radiotherapy.

Considering all stages, locoregional control rates approach 70-85% versus 50-75% with stage 4 disease following partial glossectomy, neck dissection, and postoperative radiotherapy. Overall survival rates range from 50-65%, with improved survival with early-stage disease. Even in the presence of advanced-stage disease, the mandible and larynx can be preserved in 80% of patients.

Patients with positive surgical margins are at high risk of locoregional failure and death from disease. Among patients with positive or close margins, postoperative radiotherapy doses of 60 Gy or more achieve excellent long-term local control rates. Complications for this approach include pharyngocutaneous fistula and chronic aspiration. Long-term functional outcome data demonstrate decreasing function with increasing T stage following surgical resection. The prevalence rates of regional and distant failure are approximately 20% and 30%, respectively. The actuarial incidence rate of a second primary malignancy of the upper aerodigestive tract is approximately 35% at 5 years.

In an effort to decrease the alteration in speech and swallowing function associated with extensive surgical resection of the base of the tongue, external radiotherapy alone or in combination with brachytherapy and/or neck dissection has been used as a treatment strategy. The best local control rates at 5 years with external radiotherapy alone are, for T1, 96%; for T2, 91%; for T3, 81%; and for T4, 38%.

A study by Kawaguchi et al indicated that external-beam radiotherapy can effectively treat stage T1-T3 squamous cell carcinoma of the base of the tongue. The study involved 26 patients who underwent the treatment, with the 3-year overall survival rate found to be 69% and 3-year local control for T1,  T2, T3, and T4 tumors reported to be 100%, 86%, 100%, and 20%, respectively. Three-year regional control for patients with N0, N1, N2a, N2b, N2c, and N3 lymph node involvement was 100%, 100%, 100%, 83%, 75%, and 0%, respectively. Treatment also included concurrent or neoadjuvant chemotherapy for 11 patients with advanced loco-regional disease and two or three cycles of concurrent intra-arterial cisplatin for four T3 patients and one T2 patient.[3]

Brachytherapy alone is effective for lesions smaller than 4 cm, but extensive lesions have reported local recurrence rates of as high as 50-60%. Improved local control rates approaching 80% can be achieved with the combination of external and implant radiation for T1-3 lesions.

The addition of a planned neck dissection for patients with clinically evident regional lymph node metastases offers statistically significant improved regional control (80-90%) and disease-specific survival. A brachytherapy boost (20-30 Gy) to the base of the tongue can be performed at the same anesthesia level used for the neck dissection with temporary tracheostomy.

The addition of chemotherapy to the management of advanced base of tongue carcinoma is ongoing, and the results from this treatment option are not widely reported in the literature. The 5-year disease-specific and absolute survival rates of 50-65% are comparable with surgical resection. Most recurrences are evident within the first 2 years following treatment. Complications of radiotherapy include lost of taste/saliva, tissue necrosis, and osteoradionecrosis of the mandible.

Improved quality-of-life data have been reported from selected patients treated with radiotherapy for carcinoma of the tongue base, although no prospective, randomized, or case-matched controlled studies are available in the literature. Advancing T stage is associated with decreased quality-of-life scores regardless of treatment modality. Of all head and neck subsites, treatment of base of tongue cancer has the greatest impact on speech and swallowing function and on quality of life. The addition of neck dissection to primary radiotherapy for tongue base cancer has no impact on posttreatment quality of life.

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Future and Controversies

Management of base of tongue cancer remains difficult because of the complex anatomic structure. A variety of new techniques have become available for treatment, including gene therapy and new chemotherapeutic agents. These advances in treatment have garnered great interest in an effort to control this complex anatomic site and thus reduce morbidity and mortality.

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Contributor Information and Disclosures
Author

Talib Najjar, DMD, MDS, PhD Professor of Oral and Maxillofacial Surgery and Pathology, Rutgers School of Dental Medicine

Talib Najjar, DMD, MDS, PhD is a member of the following medical societies: American Society for Clinical Pathology

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Nader Sadeghi, MD, FRCSC Professor, Otolaryngology-Head and Neck Surgery, Director of Head and Neck Surgery, George Washington University School of Medicine and Health Sciences

Nader Sadeghi, MD, FRCSC is a member of the following medical societies: American Head and Neck Society, American Thyroid Association, American Academy of Otolaryngology-Head and Neck Surgery, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

Benoit J Gosselin, MD, FRCSC Associate Professor of Surgery, Dartmouth Medical School; Director, Comprehensive Head and Neck Oncology Program, Norris Cotton Cancer Center; Staff Otolaryngologist, Division of Otolaryngology-Head and Neck Surgery, Dartmouth-Hitchcock Medical Center

Benoit J Gosselin, MD, FRCSC is a member of the following medical societies: American Head and Neck Society, American Academy of Facial Plastic and Reconstructive Surgery, North American Skull Base Society, American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, American Rhinologic Society, Canadian Medical Association, Canadian Society of Otolaryngology-Head & Neck Surgery, College of Physicians and Surgeons of Ontario, New Hampshire Medical Society, Ontario Medical Association

Disclosure: Nothing to disclose.

References
  1. Garnaes E, Kiss K, Andersen L, et al. Increasing incidence of base of tongue cancers from 2000 to 2010 due to HPV: the largest demographic study of 210 Danish patients. Br J Cancer. 2015 Jun 30. 113 (1):131-4. [Medline].

  2. Hanna E, Wanamaker J, Adelstein D, et al. Extranodal lymphomas of the head and neck. A 20-year experience. Arch Otolaryngol Head Neck Surg. 1997 Dec. 123(12):1318-23. [Medline].

  3. Kawaguchi Y, Nishiyama K, Hirata T, et al. Treatment outcomes of external-beam radiotherapy for squamous cell carcinoma of the base of the tongue. Int J Clin Oncol. 2015 Mar 3. [Medline].

  4. Candrlic B, Pusic M, Kukuljan M, Cvjetkovic N, Matana Z, Miletic D. Patient with lingual thyroid and squamous cell carcinoma of the tongue base--case report. Coll Antropol. 2012 Nov. 36 Suppl 2:227-9. [Medline].

  5. Han Y, Chen D, Li H, Zhang M, Ma S, Zhou L. [One-stage repair of pharyngeal defect using tongue flaps after resection of advanced stage hypopharyngeal neoplasm and laryngeal neoplasm]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2012 Oct. 26(10):1206-8. [Medline].

  6. Harrison LB, Lee HJ, Pfister DG, et al. Long term results of primary radiotherapy with/without neck dissection for squamous cell cancer of the base of tongue. Head Neck. 1998 Dec. 20(8):668-73. [Medline].

  7. Hmidi M, Touiheme N, Elboukhari A, Kettani M, Elmejareb C, Messary A. Primary B cell lymphoma of the tongue: a case report. Pan Afr Med J. 2012. 12:5. [Medline]. [Full Text].

  8. Horwitz EM, Frazier AJ, Vicini FA, et al. The impact of temporary iodine-125 interstitial implant boost in the primary management of squamous cell carcinoma of the oropharynx. Head Neck. 1997 May. 19(3):219-26. [Medline].

  9. Housset M, Baillet F, Dessard-Diana B, et al. A retrospective study of three treatment techniques for T1-T2 base of tongue lesions: surgery plus postoperative radiation, external radiation plus interstitial implantation and external radiation alone. Int J Radiat Oncol Biol Phys. 1987 Apr. 13(4):511-6. [Medline].

  10. Kano S, Homma A, Oridate N, Suzuki F, Hatakeyama H, Mizumachi T, et al. Superselective arterial cisplatin infusion with concomitant radiation therapy for base of tongue cancer. Oral Oncol. 2011 Jul. 47(7):665-70. [Medline].

  11. Karatzanis AD, Psychogios G, Mantsopoulos K, Zenk J, Velegrakis GA, Waldfahrer F, et al. Management of advanced carcinoma of the base of tongue. J Surg Oncol. 2012 Nov. 106(6):713-8. [Medline].

  12. Lim JH, Lim JY, Kim YM, Kim CS, Choi SJ, Yi HG, et al. Primary diffuse large B cell lymphoma of the base of tongue. J Cancer Res Ther. 2012 Jan-Mar. 8(1):135-7. [Medline].

  13. Machtay M, Perch S, Markiewicz D, et al. Combined surgery and postoperative radiotherapy for carcinoma of the base of radiotherapy for carcinoma of the base of tongue: analysis of treatment outcome and prognostic value of margin status. Head Neck. 1997 Sep. 19(6):494-9. [Medline].

  14. Martin A, Jackel MC, Christiansen H, et al. Organ preserving transoral laser microsurgery for cancer of the hypopharynx. Laryngoscope. 2008 Mar. 118(3):398-402. [Medline].

  15. Mattheis S, Mandapathil M, Rothmeier N, Lang S, Dominas N, Hoffmann TK. [Transoral robotic surgery for head and neck tumors: a series of 17 patients]. Laryngorhinootologie. 2012 Dec. 91(12):768-73. [Medline].

  16. Mehta V, Johnson P, Tassler A, Kim S, Ferris RL, Nance M, et al. A new paradigm for the diagnosis and management of unknown primary tumors of the head and neck: a role for transoral robotic surgery. Laryngoscope. 2013 Jan. 123(1):146-51. [Medline].

  17. Mendenhall WM, Stringer SP, Amdur RJ, et al. Is radiation therapy a preferred alternative to surgery for squamous cell carcinoma of the base of tongue?. J Clin Oncol. 2000 Jan. 18(1):35-42. [Medline].

  18. More YI, Tsue TT, Girod DA, Harbison J, Sykes KJ, Williams C, et al. Functional swallowing outcomes following transoral robotic surgery vs primary chemoradiotherapy in patients with advanced-stage oropharynx and supraglottis cancers. JAMA Otolaryngol Head Neck Surg. 2013 Jan. 139(1):43-8. [Medline].

  19. More YI, Tsue TT, Girod DA, Harbison J, Sykes KJ, Williams C, et al. Functional swallowing outcomes following transoral robotic surgery vs primary chemoradiotherapy in patients with advanced-stage oropharynx and supraglottis cancers. JAMA Otolaryngol Head Neck Surg. 2013 Jan. 139(1):43-8. [Medline].

  20. Park ES, Shum JW, Bui TG, Bell RB, Dierks EJ. Robotic surgery: a new approach to tumors of the tongue base, oropharynx, and hypopharynx. Oral Maxillofac Surg Clin North Am. 2013 Feb. 25(1):49-59, vi. [Medline].

  21. Rapidis AD, Vermorken JB, Bourhis J. Targeted therapies in head and neck cancer: past, present and future. Rev Recent Clin Trials. 2008 Sep. 3(3):156-66. [Medline].

  22. Remacle M, Matar N, Lawson G, Bachy V, Delos M, Nollevaux MC. Combining a new CO(2) laser wave guide with transoral robotic surgery: a feasibility study on four patients with malignant tumors. Eur Arch Otorhinolaryngol. 2011 Nov 20. [Medline].

  23. Rodgers B, Neupane P, Lominska C, Shnayder Y. Stereotactic body radiotherapy for treatment of squamous cell carcinoma of the tongue associated with human papilloma virus: a case report. Front Oncol. 2013. 3:126. [Medline]. [Full Text].

  24. Saba NF, Goodman M, Ward K, Flowers C, Ramalingam S, Owonikoko T, et al. Gender and ethnic disparities in incidence and survival of squamous cell carcinoma of the oral tongue, base of tongue, and tonsils: a surveillance, epidemiology and end results program-based analysis. Oncology. 2011. 81(1):12-20. [Medline]. [Full Text].

  25. Safa AA, Tran LM, Rege S, et al. The role of positron emission tomography in occult primary head and neck cancers. Cancer J Sci Am. 1999 Jul-Aug. 5(4):214-8. [Medline].

  26. Schuster M, Stelzle F. Outcome measurements after oral cancer treatment: speech and speech-related aspects--an overview. Oral Maxillofac Surg. 2012 Sep. 16(3):291-8. [Medline].

  27. Seikaly H, Rieger J, Wolfaardt J, et al. Functional outcomes after primary oropharyngeal cancer resection and reconstruction with the radial forearm free flap. Laryngoscope. 2003 May. 113(5):897-904. [Medline].

  28. Shin SJ, Roh JL, Choi SH, Nam SY, Kim SY, Kim SB, et al. Metastatic carcinomas to the oral cavity and oropharynx. Korean J Pathol. 2012 Jun. 46(3):266-71. [Medline]. [Full Text].

  29. Tseng WC, Chang SY, Chu PY, Tai SK, Wang YF, Shiao AS, et al. Management of base of tongue squamous cell carcinoma: experience with 85 patients in Taipei Veterans General Hospital. J Chin Med Assoc. 2011 May. 74(5):220-5. [Medline].

  30. Wu Z, Guo Z. [Relation of cytochemistry changes in the peripheral blood ANAE in chronic glomerulonephritis and differentiation-syndromes]. Zhong Xi Yi Jie He Za Zhi. 1990 Jul. 10(7):399-401, 387-8. [Medline].

  31. Zelefsky MJ, Gaynor J, Kraus D, et al. Long-term subjective functional outcome of surgery plus postoperative radiotheraphy for advanced stage oral cavity and oropharyngeal carcinoma. Am J Surg. 1996 Feb. 171(2):258-61; discussion 262. [Medline].

 
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