cT2N1 tongue cancer in a self-employed driver who wants radiotherapy only

Staging. cT2 (3.5 cm, depth 9 mm) N1 (single ipsilateral node 2.5 cm, no extranodal extension) M0 - stage III. He is performance status 0–1.

Both are oncologically legitimate. For early and intermediate oral cavity cancer, surgery and radiotherapy achieve broadly comparable locoregional control and survival when delivered well. The choice is therefore driven by function, morbidity, logistics and the need for pathological information.

Why surgery first is preferred here. (1) Wide local excision with an ipsilateral selective neck dissection (levels I–IV) gives definitive pathological staging of both the primary and the neck, including depth of invasion and extranodal extension, which determines whether he needs adjuvant treatment at all. (2) Radiotherapy fields for a tongue primary plus ipsilateral neck will include the contralateral neck or at least a large volume of salivary tissue, causing permanent xerostomia, taste change and a lifelong elevation of osteoradionecrosis risk; these matter in a man who drinks heavily and may need dental work. (3) Treatment time is shorter overall, and radiotherapy remains available if he recurs. (4) A negative neck dissection also avoids the small but real risk of missing occult nodal disease.

Why radiotherapy may still be chosen. If he cannot tolerate a general anaesthetic, has unresectable disease (not the case), or declines surgery after full information. Definitive radiotherapy is 6–7 weeks of daily attendance with mucositis, dysgeusia, xerostomia, fatigue and a significant impact on driving shifts - which undercuts his assumption that it will let him work.

Recommendation. Offer primary surgery with neck dissection, and be explicit that adjuvant radiotherapy may still be needed afterwards. Document the alternatives discussion and his priorities.

Aim. A 1.5–2 cm mucosal margin measured on the specimen, with the deep margin taken en bloc and assessed, and intraoperative frozen section of the mucosal and deep margins where available. Frozen section reduces but does not abolish the risk of a close final margin; it is less reliable for dysplasia, so final paraffin histology decides.

Close margin (less than 5 mm but not at the margin). This is an indication for postoperative radiotherapy, particularly if there are other adverse features. It is not automatically an indication for re-resection.

Involved margin (tumour at the inked margin). The choices are re-resection, which is preferred when the defect is accessible and re-excision can be done without unacceptable functional loss, or postoperative radiotherapy with a boost, which is chosen when re-resection would mean a total glossectomy or a second free flap. Discuss in a multidisciplinary meeting and with the patient.

Other adverse features and their weight. Close margin, depth of invasion greater than about 10 mm, perineural invasion, lymphovascular invasion, pT3/T4, multiple positive nodes, and any extranodal extension. Extranodal extension, especially gross extranodal extension, is the strongest indication for concurrent cisplatin with radiotherapy (about 60–66 Gy, with three-weekly or weekly cisplatin) rather than radiotherapy alone. If the neck dissection is pN0 with clear margins and no other risk features, he may be able to avoid radiotherapy altogether, which is a major argument for operating first. Note that his 9 mm depth of invasion sits close to the threshold used in many protocols and would be weighed with other features.

Neck. Ipsilateral selective neck dissection of levels I–IV, since level IV is a recognised drainage route for tongue primaries and level I is clinically involved. Contralateral neck dissection is not indicated for a lateralised T2 with a single ipsilateral node, but the contralateral neck should be discussed at the multidisciplinary meeting if the primary approaches the midline. In a clinically N1 neck, a supraomohyoid-type selective dissection rather than a modified radical dissection is appropriate.

Defect and reconstruction. A 3.5 cm resection with 9 mm depth will usually be a partial or hemiglossectomy. If less than about a third of the tongue is removed with mobile remaining tissue and the defect can be closed without tethering, primary closure or healing by secondary intention is possible but risks ankyloglossia and poor tongue mobility. For a hemiglossectomy, or where adjuvant radiotherapy is likely, reconstruct with a free radial forearm fasciocutaneous flap - thin, pliable and allows tongue mobility, with good speech and swallow outcomes. A bulkier anterolateral thigh flap is reserved for larger composite defects. If mandible is not resected, no osseous reconstruction is needed. Plan the airway: most of these patients can be managed without a tracheostomy, but consent for one if the tongue base or floor of mouth is extensively resected.

Counselling about recovery. Expect 5–10 days in hospital, a nasogastric or gastrostomy feeding route initially, and a return to normal diet over 4–6 weeks with speech and swallowing therapy. Free flap donor-site and flap monitoring requirements mean he cannot drive for at least 2–4 weeks after surgery (longer with adjuvant radiotherapy), and he should plan financially for 6–8 weeks off work, more if radiotherapy follows. Offer to involve a social worker or welfare adviser and to write to his GP about fitness to drive, since his livelihood depends on it.