Japanese Journal of Clinical Oncology Advance Access originally published online on January 17, 2006
Japanese Journal of Clinical Oncology 2006 36(1):3-6; doi:10.1093/jjco/hyi218
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© 2006 Foundation for Promotion of Cancer Research
Is Glossectomy Necessary for Late Nodal Metastases without Clinical Local Recurrence after Initial Brachytherapy for N0 Tongue Cancer? A Retrospective Experience in 111 Patients Who Received Salvage Therapy for Cervical Failure
1 Department of Clinical Radiology, 2 Department of Clinical Otolaryngology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, 3 Department of Clinical Radiology, Saiseikai Fukuoka General Hospital, Fukuoka, 4 Department of Oral and Maxillofacial Radiology, Kyushu University Hospital, Fukuoka, 5 Department of Radiology, St. Mary's Hospital, Fukuoka and 6 Department of Radiologic Technology, School of Health Sciences, Kyushu University, Fukuoka, Japan
For reprints and all correspondence: Yusuke Urashima, Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan. E-mail: urash{at}radiol.med.kyushu-u.ac.jp
Received January 24, 2005; accepted November 29, 2005
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Abstract |
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 TOP Abstract INTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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Purpose: To assess the efficacy of neck dissection (ND) without glossectomy (GL) for late nodal metastases without local recurrence after brachytherapy for N0 tongue cancer.
Materials and methods: Among 396 patients with N0 tongue cancer treated with brachytherapy, a retrospective analysis was performed in 111 patients who were clinically diagnosed as having nodal metastases without local recurrence and whose neck lymph nodes turned out to be pathologically positive after salvage surgery. One hundred and five patients had undergone only ND (the ND group), six patients had undergone ND with GL (the ND+GL group).
Results: The 5 year disease-free and cause-specific survival rates after salvage therapy for the 111 patients included in this study were 58.1 and 61.9%, respectively. In the ND group, there were only nine patients who had local recurrence after ND. In addition, only six patients (5.7%) had a local recurrence within 2 years in the ND group. Sixty-three patients were free of disease after ND, 31 patients had regional or distant metastases without local recurrence and two patients had progressive disease at ND. In the ND+GL group, four patients were alive without disease and two died from regional or distant metastases. None of the patients in the ND+GL group were found to have malignant tissue in the pathological findings from the excised tongue.
Conclusion: GL should be avoided or suspended when the clinical evaluation had revealed cervical failure without apparent local recurrence in the mobile tongue cancer patients after initial brachytherapy.
Key Words: brachytherapy • salvage therapy • tongue neoplasms
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INTRODUCTION |
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It has generally been accepted that brachytherapy for the treatment of early tongue cancer is an excellent means of achieving local control (1–3). Brachytherapy also makes it possible to preserve the shape and the function of the oral tongue. However, cervical lymph node metastases develop in some patients, even when the primary tumor has apparently been controlled. The prognosis of early tongue cancer is strongly related to regional control rather than to local control (4,5), and neck dissection (ND) has been established as salvage therapy for cases of cervical failure after initial brachytherapy (1,6). However, there is no consensus regarding whether glossectomy (GL) should be combined with ND when local recurrence is not clinically apparent. Some investigators have recommend ‘en bloc resection’, i.e. GL combined with ND, even in patients without local recurrence at the time of the recurrence of neck metastases (6,7); however only a small number of reports have discussed the efficacy of GL combined with ND.
In an attempt to develop an optimal treatment for tongue carcinoma, we performed retrospective analyses of case studies without clinical local failure at the time of the diagnosis of neck metastases after brachytherapy for N0 tongue cancer.
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MATERIALS AND METHODS |
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We reviewed the records of 397 patients with carcinoma of the mobile tongue who had undergone brachytherapy at the Kyushu University Hospital between 1978 and 2000, inclusively. Among the 397 patients, 111 patients were studied, who had late pathological nodal metastasis without clinical local recurrence. Of these 111 patients, 105 underwent ND alone (the ND group), six underwent ND with GL (the ND+GL group). The treatment strategy was in part determined by the opinion of radiation oncologists, who strongly recommended preservation of the treated tongue in view of the preservation of the quality of life. Following initial treatment, the tongue and neck nodes were closely followed for signs of recurrence or metastasis once a month during the first and second year and once every 2 or 3 months thereafter. To evaluate the tongue, we performed careful inspection and palpation. Biopsy was also performed if necessary. To evaluate neck nodes, we basically performed ultrasonographic examination at least once every 2 months after brachytherapy within 2 years during follow-up period and performed CT or MRI if necessary.
Among 111 patients, 56 males and 55 females were included in the study (age range: 21–81 years; mean age: 53 years). At the time of initial brachytherapy, the tumor stages were T1 in 44 patients, T2 in 59 patients, T3 in seven patients and T4 in one patient, according to the UICC (2002) classification. All of the 111 patients belonged to the N0 category, i.e. none of them had clinical evidence of neck node metastases. The histological variants of the primary tongue tumors were 108 squamous cell carcinomas, two mucoepidermoid carcinomas and one adenocarcinoma. Interstitial brachytherapy was performed with radium needles in 99 patients, cesium needles in eight patients and 192Ir hairpins in four patients. Radiation doses were delivered by the implantation of radioactive sources, and doses reached 
70 Gy/week, according to the Paterson–Paker dosage system. Among the 111 patients, 69 were treated with brachytherapy alone and the remaining 42 patients were treated by a combination of chemotherapy and/or external radiotherapy, with a median dose of 19.8 Gy (range: 6.0–40.0 Gy). All patients achieved a complete response, with a median disease-free interval of 5.1 months (range: 0.8–60.0 months). At the time of cervical failure, all patients had no clinical evidence of local recurrence. Radical ND was performed in 101 of the 111 patients and 10 patients received supraomohyoid ND or removal of metastatic nodes. Of 111 patients, six underwent radical ND combined with hemiglossectomy.
Most of the patients were followed for at least 5 years or until death. The follow-up period ranged from 4.0 months to 272.0 months (median: 78.4 months). The duration between the date of salvage treatment and the date of the last follow-up was used for the calculation of Kaplan–Meier survival curves.
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RESULTS |
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In the ND group, 103 patients succeeded in salvage therapy, but two patients had progressive disease at ND. Among the 103 patients, 63 were free of disease after ND, 31 had regional or distant metastases without local recurrence, five had regional or distant metastases with local recurrence and four had local recurrence alone. A total of nine patients in the ND group had a local recurrence after salvage surgery (Fig. 1). The duration between salvage therapy and local recurrence ranged from 9.2 months to 141.0 months. Within 2 years after salvage therapy, only six patients had a local recurrence.
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In the ND+GL group, four patients were alive without disease and two died from regional or distant metastases (Fig. 1). None of these six patients was found to have malignant tissue by pathological examination of the excised tongue conducted at the time of salvage therapy.
The 5 year disease-free and cause-specific survival rates after salvage therapy for the 111 patients included in this study were 58.1 and 61.9%, respectively (Fig. 2). The 5 year cause-specific survival rate for patients in the ND group was 61.6%, compared with 66.7% in the ND+GL group (Fig. 3).
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DISCUSSION |
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TOPAbstractINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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Radiotherapy and, in particular, brachytherapy provides a higher local rate of control in the treatment of early tongue cancer than does surgery (1,8,9). On the other hand, regional metastasis is considered as an important prognostic factor of early tongue cancer (5,10). If regional nodes are present after the initial treatment, the prognosis is considerably worse.
As regards the cervical treatment of N0 tongue cancer patients, several treatment options are available, including prophylactic ND, therapeutic ND and prophylactic irradiation. However, the best approach for the treatment of the neck in N0 tongue cancer patients remains controversial. Several studies have suggested that elective ND or prophylactic irradiation should be performed in patients with N0 tongue cancer (11,12). In a study of ND, Vandenbrouck et al. (13) conducted a prospective randomized trial to compare elective versus therapeutic ND. Their study was based on 75 patients with epidermoid carcinoma of the oral tongue or of the floor of the mouth. The incidence of nodal involvement was the same, regardless of whether elective or therapeutic ND was used (49 and 47%, respectively), and the survival curves revealed no significant difference between the two approaches. In contrast to the authors of that study, who recommended aggressive treatment, other investigators have recommended careful observation and salvage therapy at the time of diagnosis of cervical failure (14,15). Benk et al. (14) studied 110 patients with Stage I and Stage II epidermoid carcinomas of the mobile tongue, and they investigated the outcomes of 85 patients who had been treated by interstitial irradiation and had received either elective ND or surveillance and therapeutic ND for neck relapse. They reported that no significant difference was seen in regional control in terms of the neck management policy used. They concluded that there is no disadvantage in neck control when patients are closely followed and if therapeutic ND combined with neck irradiation is used for patients with a neck relapse. Nakagawa et al. (15) presented the data from 616 tongue cancer patients who received primary interstitial radiotherapy. They demonstrated that the macroscopic appearance of the tongue cancer had a major impact on the incidence of nodal metastasis and invasive /ulcerative types of tongue cancer had a higher incidence rate (62%) of nodal metastasis than did superficial and exophytic/nodular types of tongue cancer (20 and 35%). They recommended that the treatment policy for clinically negative neck metastasis in patients with early tongue cancer should be determined after considering the possibility of neck metastasis. At our institution, the radiation oncologists recommend a wait-and-see policy for patients with N0 tongue cancer who undergo initial brachytherapy. In addition, close follow-up with a manual clinical examination is also conducted, at times together with ultrasonography, because such a wait-and-see policy is associated with a risk of failure to detect an early metastasis. Further investigation is still necessary to reveal the optimum cervical treatment strategy for patients with N0 tongue cancer.
As regards the management of patients with cervical failure after initial brachytherapy, surgery is the standard form of treatment. Radical ND or regional ND is often performed, but some investigators have also advocated further treatment aiming at an improvement in locoregional control. Kurita et al. (6) reported 13 patients with delayed lymph node metastases, which developed after control of primary lesions of the tongue had been attained with radiotherapy or by surgical resection. Of these 13 patients, 12 patients received radical ND with or without external radiotherapy and one received en bloc resection of both the tongue and the metastatic neck. Six patients developed tumors in the neck, and in particular, in the ‘untreated area’, i.e. in the area between the site of the primary lesion and the regional lymph nodes. That study emphasized the importance of ND with external radiotherapy or en bloc resection with ND in terms of the centrifugal spread of regional lymphatic drainage after radical ND. However, the number of patients included in that study was not sufficient to support the efficacy of GL with ND. Satake et al. (7) recommended ND with hemiglossectomy for cases in which metastatic nodes are present or suspected; their recommendations were based on the analysis of 46 patients with tongue cancer treated by ND in combination with brachytherapy or GL. However, of those 46 patients, 27 were undergoing initial treatment and only 19 were treated by ND alone at the time of the recurrence of primary lesions or cervical metastases. Although that study showed a better 2 year survival rate of 84.6% in 13 cases treated by ND with GL as the initial treatment, as compared with the 46.7% survival rate in the 19 cases treated with ND alone as a secondary treatment, the efficacy of treatment by ND with GL remained unclear in patients with neck metastases in the absence of clinically determined local failure after brachytherapy.
In our study, only six patients (5.7%) had a local recurrence within 2 years in the ND group. For these six patients, ND combined with GL could have been an optional salvage therapy because of the possibility of a viable lesion at the time of cervical failure. However, performing GL in all of these patients might have been considered as an excessive option for most of these patients who had clinically diagnosed positive nodes without clinically diagnosed local recurrence. In addition, none of the patients in the ND+GL group were found to have had a local recurrence in their excised tongue. The surgical procedure can achieve a high local control rate, but it is accompanied by a significant loss in the volume of the tongue. GL may reduce the quality of life of patients who have late nodal metastases without clinical local recurrence. Therefore, we recommend that ND without GL should be chosen for patients who have late nodal metastases without clinical local recurrence.
In conclusion, our results indicate that GL may not be a significantly effective treatment for patients whose clinical evaluation shows cervical failure without apparent local recurrence. However, close follow-up of such patients is necessary for the early detection of a local recurrence.
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Acknowledgments |
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This study was presented at the 45th Annual Meeting of the American Society for Therapeutic Radiology and Oncology, 19–23 October 2003, Salt Lake City, Utah.
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References |
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