Base of Tongue

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T1 and T2 lesions can be successfully treated by either surgery or radiation therapy. Both modalities have equivalent local control and survival rates. Local control rates of 80 to 90 percent for radiation43 and 75 to 85 percent for surgery44,45 have been reported. The therapeutic decision will need to be based on the morbidity of one treatment compared to the other. The majority of patients are usually treated with radiation therapy, as it provides a better functional outcome and quality of life with equivalent control rates. Surgery would be indicated for patients with endophytic, locally advanced lesions which may be difficult to control with radiation alone. In such cases, postoperative radiation therapy may be necessary. Such radiation would commence within 6 weeks following surgery using conventional fraction-ation delivering 6,300 cGy to the high-risk primary site and nodal levels, with 5,000 to 5,400 cGy administered for elective nodal irradiation.

Figure 21-5. Simulation (A, C) and corresponding port films (B, D) for a patient with a T3N2b squamous cell carcinoma of the tonsillar region.

At Memorial Sloan-Kettering Cancer Center, patients with T1 and T2 lesions would be considered for treatment with radiotherapy conventional fraction-ation with the primary lesion taken to 5,400 cGy, the involved neck nodes to 6,000 cGy and elective nodal irradiation to 5,000 to 5,400cGy (Figures 21-6A and B). Following a 3-week break, the patient would undergo a neck dissection for clinically positive nodes and an elective tracheotomy, as well as an iridium 192 temporary interstitiary implant to the base of the tongue delivering 2,400 to 3,000 cGy. Local control rates have been reported at up to 100 percent for the T1 and T2 lesions treated with this approach.46-48 Also, such early T stage patients would be considered for full course accelerated fractionation external beam radiation with a delayed concomitant boost alone or with concurrent cisplatin chemotherapy with patients who have cervical adenopathy where neck dissection would generally follow.

Selected exophytic early T3 lesions may still be approachable with full course radiation therapy as described above. Local control rates of 80 percent have been obtained with this approach.46-49

Advanced T3 and T4 lesions often would require surgery with a partial or total glossectomy, possibly a total laryngectomy and neck dissection to be followed with postoperative radiation therapy. The results with surgery alone for these advanced lesions has been reported at a 27 percent 2-year local control and a 20 percent overall survival.50 Radiation therapy alone has been reported to have a 50 percent local control rate. Combining surgery with postoperative radiation therapy has a local control rate of 75 to 90 percent.45 In such cases, it is currently reasonable to consider a larynx preservation approach, with chemo-radiation

At Memorial Sloan-Kettering Cancer Center, very advanced or unresectable lesions are preferentially treated on our research protocol with cisplatin chemotherapy on days 1 and 22 concurrent with radiation therapy using accelerated fractionation with a delayed concomitant boost to a dosage of 7,000 cGy to the primary lesion and lymphadenopa-thy; 5,000 to 5,400 cGy is administered for elective nodal irradiation (Figures 21-7A and B). Patients with an initially positive neck would undergo a neck dissection approximately 6 weeks after treatment.

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