TRANSHYOID APPROACH IN SURGERY OF TONGUEBASE NEOPLASMS

INTRODUCTION

Tongue base neoplasms are characterized in generally

by a bad prognosis (1, 2).

This situation is the result of late presentation to the

specialist and of the difficulties often encountered in

correct diagnostication of this disease.

Early simptomatology is poor, advanced stages being

almost constantly characterised by the presence of

adenopaty.

The principles of treatment suffered many

transformations and readaptations in last decades, even

today still being characterized by heterogenity of

therapeutic models used in different institutions world

wide.

Traditional methods include unimodal treatment,

consisting of surgery or radiation therapy alone, and

combined treatment which uses the combination

between these two methods.

34

Journal of Experimental Medical & Surgical Research

Cercetãri Experimentale & Medico-Chirurgicale

Year XVIII · Nr.1/2011 · Pag. 34 - 38E x p e r i m e n t a l

M e d i c a l S u r g i c a l

R E S E A R C H

J O U R N A L o f

Correspondence to: R.D. Cristescu, Clinica ORL Timiºoara, Bd. Revolutiei 6, 300054 Timisoara, email: dragos_cristescu2004@yahoo.com.

SUMMARY: The treatment of tongue base neoplasms is evolving continuously, remainingcontroversial in the same time, as it was 25 years ago.From the variety of technicues utilized in tongue base tumor surgery, tumor resection usingtranshyoid approach provides similar oncologic results with other surgical technicues ,having the advantage of superior functional results.A retrospective study was conducted on 35 patients treated surgically for tongue baseneoplasms in ENT Department Timisoara between 1998 and 2010.All cases were stadialised according to the UICC. Four patients wee classified in stage II, 12 patients in stage III and 19 patients in stage IV.Most common histological type encountered was the squamous cell carcinoma.Tumor resection was performed using the transhyoid approach in all cases.Surgical treatment remains an useful alternative in tongue base cancer therapy, offeringexcellet results especially when associated with adjuvant therapies.Keywords: tongue base, neoplasms, transhyoid approach.

Rezumat: Tratamentul neoplasmelor bazei de limba evolueaza continuu, ramanand inacelasi timp controversat, la fel ca si in urma cu 25 ani.In cadrul diverselor tehnici chirurgicale destinate acestei patologii, metoda aborduluitranshioidian ofera rezultate oncologice similare celorlalte tehnici, detinand avantajul unorrezultate functionale superioare.A fost realizat un studiu retrospectiv pe 35 pacienti tratati chirurgical pentru neoplasme alebazei de limba in Clinica O.R.L. Timisoara intre anii 1998 - 2010.Cazurile au fost stadializate conform sistemului UICC de stadializare.Patru pacienti au fostincadrati in stadiul II, 12 pacienti in stadiul III si 19 pacienti in stadiul IV.Cel mai frecvent diagnostic histopatologic a fost carcinomul scuamocelular.S- a realizat rezectia tumorala prin abord transhioidian in toate cazurile.Tratamentul chirurgical ramane in continuare o alternativa eficienta in tratamentulneoplaziilor bazei limbii, oferind rezultate excelente atunci cand este utilizat in asociere cucelelalte metode terapeutice.Cuvinte cheie: baza limbii, neoplasme, abord transhioidian..

R.D. Cristescu1 , S. Cotulbea1, S. Lupescu1, A. H. Marin1,G. Iovanescu1, V. Draganescu1,H. Stefanescu1,C. Doros1,N. Balica1,Anamaria Mag1, Andreea Ruja2

Received for publication: 11.11.2010

Revised: 08.01.2012

1. - Clinica ORL Timisoara-Universitatea de Medicina si Farmacie "Victor Babes" 2. - Clinica de Odontoterapie si Endodontie-Facultatea de Medicina Dentara

Recently, combining radiotherapy with chemotherapy

in various radiochemotherapic protocols ,is gaining

popularity as a preffered option of treatment, due to the

advantage of superior preservation for organs and their

functions, but prohibitive prices are still limiting their use

on a large scale.

The selection of adequate therapy for these patients

depends on the stage of the disease, type of tumour and

the associated comorbidities.

For tumours in early stages (T1), radiotherapy is the

treatment of first choice because of its excellent

therapeutic results combined with minimal added

morbidity.

More advanced stages (T2,T3,T4) need combined

treatment, represented by surgery and postoperative

radiotherapy, associated or not with chemotherapy.

Among various techniques used in the surgery of

tongue base neoplasms, tumor resection using the

transhyoid approach offers certain advantages, making

this technique very useful ,especially when combinated

with radiation therapy.

This study presents the experience of the ENT

Department Timisoara in the treatment of tongue base

neoplasms using the transhyoid approach.

MATERIALS AND METHODS

A retrospective chart review was performed in 35

patients who were surgically treated for tongue base

neoplasms at the ENT Department of Timisoara between

1998 and 2010.

All patients underwent preoperative laryngoscopy

and advanced imaging studies (computed tomography

and/or magnetic resonance imaging) to evaluate the

surgical feasibility of the tumour.The patient`s disease

was staged according to the most recent

recommendations of the Union for International Cancer

Control (UICC).

In all cases, the tumour resection was performed by

using the transhyoid approach

All patients underwent simultaneous bilateral

selective neck dissections and also underwent

postoperative radiation therapy.

RESULTS

Twenty-nine patients were men with the age range

between 43 to 67 years (average age,51,86 years) and 6

patients were women with the age range between 47 to

79 years (average age,59 years) (Table 1).

The minimum follow-up period was 12 month (range

of follow-up, 12 -144 months).

Clinical symptomatology at the first medical

presentation is noted in Table 2.

Seven patients had T2 tumours,14 patients had T3

tumours and 14 patients had T4 tumours. A large

proportion of the patient`s disease was categorized into

Union for International Cancer Control stage III (12

patients) or IV disease (19 patients), as a result of the

numerous cases presenting advanced local disease and

due to the high incidence of regional nodal metastasis.

35

Age decades Number of case Percentage

40-49 13 37,14%

50-59 14 40%

60-69 7 20%

70-79 1 2,85%

Table 1. Distribution by age decades.

Clinical signs and symptomsNumberof cases

Percentage

Sore throat 32 91,42%

Dysphagia 35 100%

Odynophagia 35 100%

Reffered ear pain 10 28,57%

Irritative cough 2 5,71%

Clinical adenopathy 29 82,85%

Table 2. Clinical symptomatology.

T stage

N stageT1 T2 T3 T4

N0 0 4 1 1

N1 0 1 10 9

N2 0 2 3 4

Table 3. Distribution of TNM stage.

Surgical intervention Numberof case

Percentage

Resection of tongue base 16 45,71%

Epiglottectomy with tongue base tumor resection

13 37,14%

Supraglottic laringectomywith tongue base tumorresection

6 17,14%

Table 4. Surgical procedures.

Only 4 patients were categorized as stage II and no

patient`s disease was categorized as stage I (Table 3).

All interventions were performed under general

anesthesia.Tracheotomy was done in all cases, either

preoperatively or intraoperatively.

Tumoral resection was realized via transhyoid

pharyngotomy, with simultaneous intraoperative bilateral

neck dissection (Selective Neck Dissection) in all cases.

Defect was closed primary.

In 16 cases having tumors which interested only the

base of tongue, it was performed the rezection of tongue

base by transhyoid pharyngotomy (Fig.1,2,3,4 and 5).

In the other 19 cases, where tumors presented

extension to the supraglottic larynx structures, it was

performed epiglottectomy.witht tongue base tumor

resection or supraglottic laringectomy with tongue base

tumor resection (Table 4) .

Hystopathological findings were represented in the

majority of cases (30 patients) by scuamous cell

carcinoma in various degrees of tumour differentiation,

most frequent G2 and G3 degrees.

Other findings were represented by carcinoma "in situ"

in 2 cases, anaplastic carcinoma in 1 case,

mucoepidermoid carcinoma in 1 case and

adenocarcinoma in 1 case (Table 5).

Of the 35 patients, 32 (91,42%) had clear margins in

the final pathologic specimen.

For 2 patients were confirmed the clinically negative

neck (out of 6 patients N0) and for 2 patients were nodal

metastases.

For 24 patients were confirmed the clinically positive

neck (out of 29 patients N+).

36

Fig.1. Preoperative faringo-laringoscopy

Fig.2. Preoperative CT

Fig.4. The resection specimen.

Fig.3. Intraoperative aspect

Fig.5. Postoperative 6 years aspect

None of the patients developed immediate

complications such as infection of the wound, necrosis or

fistula.

Functional results were assessed by evaluating

postoperative deglutition and speech.

Deglutition resumed for all patients, immediately after

removal of the nazogastric feeding tube. Seven patients

(20%) presented temporary difficulties of feeding, but

swallowing was good after 10-14 days.

Speech was good for 31 patients (88,57%).Four

patients (11,43%) presented poor speech due to

impossibility of decanulation for a longer period.

Death rate in the follow up period was 25% (8

patients).

Three patients developed tumoral recurrence and died

at 3,6 and 12 months postoperati- vely, 2 patients died

from other patologies at 12 and 18 months

postoperatively and 3 patients developed lung

metastasis and died at 12, 18 and 26 months

postoperatively.

Twenty-seven patients were free of locoregional

recurrence or distant metastasis, disease- free survival

rate being 75% in the follow up period.

There were no significant differences in the response

to therapy, between patients with scuamous cell

carcinomas and the others having non scuamous cell

carcinomas.

COMMENTS

Tongue base cancers can be resected through 3 main

surgical approaches.These include the transoral,

transmandibular and transpharyngeal approaches.

Transoral approach has limited indications,

represented by small sized tumors of tongue

base.Resection is most often performed by using CO2

laser.

Steiner et al. (3) have advocated the use of CO2 laser

for squamous cell carcinoma of the base of the tongue in

selected patients with good oncological and functional

results.

Transmandibular approach provides the advantages of

a wide tumor exposure, being indicated in large

oropharyngeal tumors.His main disadvantages consist in

significant secondary morbidity, including lip and chin

scars, malocclusion, compromised deglutition, chronic

aspiration and altered speech articulation.

Although the transhyoid approach to the pharynx has

been classically described during the initial approach to

lesions involving the supraglottic larynx ,its potential

utility in providing access to other sites within the

pharynx has been historically recognized.

Since its first description by Jeremitsch in 1895,

several authors(4,5,6,7) have reported on its use.

Ferris and Meyers (8) described the " secrets for

success" as being accurate assessment of the tumor in

preoperative planning and meticulous attention to detail

intraoperatively.

Their preoperative selection criteria include patients

with tumor limited to the tongue base (posterior to the

circumvallate papillae), T1/T2 tumors of the tongue base,

tumors not involving the pre-epiglottic space and patients

with good pulmonary performance.

Moore and Calcaterra (9) reported oncological

success even in T3 squamous cell carcinoma of the

tongue base using the transhyoid approach.

Historically, stage III and IV tongue base tumours have

been associated with poor outcome.

Researches showed that the biologic behavior of

squamous cell carcinoma of tongue base is governed by

the size and depth of the tumor rather than the nodal

stage and that locoregional metastases do not

significantly impair survival.(10,11 ).

Zeitels et al. (12) also evaluated 15 patients who had

mostly T3 and T4 tongue base tumors that were resected

via a transoral-transhyoid method.All patients had

primary closure and clear margins in the final pathologic

specimen.None of the patients had problems with

aspiration, and all patients resumed an oral diet within 3

weeks.Their only complication was a

pharyngocutaneous fistula, which resolved with

conservative measures.

Transhyoid resection of tongue base tumors results in

significantly lower morbidity than do the transmandibular

methods.

Authors like Nasri, Civantos and Wenig, realized

comparative studies between patients treated by using

the transhyoid approach and patients treated with

composite resection or mandibulotomy.In their studies,

they did not see any significant difference between the 2

37

Hystopathologic typeNumber of

casesPercenta

ge

Scuamous cell carcinoma 30 85,71%

“In situ” carcinoma 2 5,71%

Anaplastic carcinoma 1 2,85%

Mucoepidermoidcarcinoma

1 2,85%

Adenocarcinoma 1 2,85%

Table 5. Hystopathological findings.

groups in disease-free survival, status of surgical

margins, recurrences, or complications.However , they

did observed significantly superior postoperative speech

and swallowing function in the transhyoid group.

Association of postoperative radiation therapy to the

surgical resection improves substantially the rates of

local control in these cases (13,14).

CONCLUSIONS

Among various techniques used in the surgery of

tongue base neoplasms, tumor resection using the

transhyoid approach offers the advantages of an

excellent tumor exposure, low postoperative morbidity,

and local control rates similar to the other techniques.

The advantages of the transhyoid approach to the

neoplasms of tongue base in conjunction with neck

dissection and postoperative radiation therapy, include

excellent long- term patient survival, improved

swallowing and speech function, outstanding tumor

exposure, and minimal cosmetic deformity.

38

References:1. Alvi A, J. Johnson.Development of distant metastasis after treatment of advanced-stage head and neck cancer.Head Neck

1997;19:500-505.2. American Joint Committee on Cancer (including base of tongue, soft palate, and uvula). In: AJCC Cancer Staging Atlas. Greene, F,

Compton, C, Fritz, A, Shah, J, Winchester D, editors. New York ; Springer; 2006: 27-40.3. Steiner W, Fierek O, Ambrosch P, Hommerisch CP, Kron M.Transoral laser microsurgery for squamous cell carcinoma of the base

of tongue. Arch Otolaryngol Head and Neck Surg 2003; 129(1):36-43.4. Nasri S, Oh Y, Calcaterra TC. Transpharyngeal approach to the base of tongue tumors: a comparative study. Laryngoscope

1996;106: 945-950.5. Metternich FU, Puder C, Brusis T. Suprahyoid pharyngotomy for surgical therapy of malignant and benign oral and

hypopharyngeal tumors.HNO 1996; 44:242-245.6. Schechter GL, Sly DE, Roper AL, et al.Set-back tongue flap for carcinoma of the tongue base. Arch Otolaryngol. 1980;

106:6680671.7. Weber PC, Johnson JT, Meyers EN. The suprahyoid approach for squamous cell carcinoma of the base of the tongue.

Laryngoscope. 1992;102:637-640.8. Ferris FL, Meyers RN. Suprahyoid pharyngotomy. Operatives technicues in Otolaryngology. Head and Neck Surgery 2005;

16(1):49-54.9. Moore DM, Calcaterra TC. Cancer of the tongue base treated by a transpharyngeal approach.Ann Otol Rhinol Laryngol

1990;9:300-303.10. Freeman DE, Mendenhall WM, Parsons JT, Million RR.Does neck stage influence local control in squamous cell carcinoma of the

head and neck ? Int J Radiat Oncol Biol Phys. 1992; 23: 733-736.11. Richard JM, Sancho-Garnier H, Micheau C, Saravane D, Cachin Y. Prognostic factors in cervical lymph node metastasis in upper

respiratory and digestive tract carcinomas: study of 1,713 cases during a 15-year period. Laryngoscope. 1987; 97: 97-101.12. Zeitels SM, Vaughan CW, Ruh S.Suprahyoid pharyngotomy for oropharynx cancer including the tongue base. Arch Otolaryngol

Head Neck Surg. 1991;117:757-760.13. Nisi K, et al. Adjuvant radiotherapy for squamous cell carcinoma of the tongue base: improved local-regional disease control

compared with surgery alone.International J Radiat Oncol Biol Phys 1998; 41:371-377.14. Weber P, Myers E, Johnson J.Squamous cell carcinoma of the base of tongue. Eur Arch Oto-rhino-laryngol 1993; 250:63-68.