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Treatment

Medical Therapy

The choice of 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.

Squamous cell carcinoma

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 Brachytherapy boost (20-30 Gy) to the base of the tongue has been used in the past but has largely been replaced by three dimensional radiotherapy treatment planning.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.

Surgical Therapy

The choice of treatment for base of tongue carcinoma is controversial, with options including surgery alone, radiotherapy alone, or multimodality treatment. Tumors of the tongue base 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. These advanced surgical techniques require additional training and equipment to be performed but reported results are promising.

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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Treatment of base of tongue cancer with paclitaxel, ifosfamide, and cisplatinum induction chemotherapy followed by chemoradiotherapy.

• OBJECTIVES/HYPOTHESIS: To assess the efficacy of paclitaxel, ifosfamide, and cisplatinum induction chemotherapy plus concurrent chemoradiation in the treatment of stage III and IV base of tongue cancer.
• STUDY DESIGN: Subgroup analysis of patients with base of tongue cancer enrolled in a single-institution prospective phase II trial, evaluating an organ-preservation approach in the treatment of locally advanced head and neck cancer.
• METHODS: Eighteen patients with tumors ranging from stage T2-T4, any N, or M0 were treated with a protocol of induction chemotherapy, with Taxol, ifosfamide, cisplatin every 21 days for up to three cycles. If the primary tumor exhibited a complete or partial response, patients were treated with radiation and weekly taxol and carboplatin for 7 weeks. Surgery was used for those with less than partial response or disease progression. Neck dissection was performed in cases with clinical or radiological evidence of persistent disease in the neck 6 to 8 weeks after completion of treatment.
• RESULTS: Sixteen patients were male and two were female; the average age was 55 years (range, 43-65). Fifteen patients had stage IV disease and three had stage III disease. Of the 18 patients initially enrolled, 17 patients had a complete response. All 17 patients had no evidence of loco-regional disease at a median follow-up of 29.6 months. Only 1 of them developed distant metastases 30 months after completion of treatment. Three patients required permanent percutaneous endoscopic gastrostomy tubes because of severe dysphagia associated with concurrent chemoradiation.
• CONCLUSIONS: The treatment regimen studied is remarkably effective in stage III and IV base of tongue cancer with 100% of patients completing the protocol alive to date. Although some patients required persistent percutaneous endoscopic gastrostomy use, no patient experienced significant enough toxicity during the protocol to delay or withdraw from treatment.