In locally aggressive thyroid cancer, panelists agreed that evaluating vocal cord function was a high priority. “You have to understand the function of the cords before you go into any thyroidectomy,” said Dr. Freeman.
Explore This IssueApril 2006
Managing Tongue and Tonsil Cancer
Another issue addressed was management of a Stage IV carcinoma of the base of the tongue. Panelists concurred that the use of chemoradiation alone was appropriate for many cases, but some patients would need neck dissection as well. When it came to the treatment of patients with T2N2 tonsil cancer, chemoradiation therapy was the preferred choice and represents a shift in practice.
“During my training the standard was to do a tonsillectomy and neck resection, and if the nodes were positive then post-operative radiation therapy. Now, about 90% of our patients will get chemoradiation therapy,” Dr. Shaha said.
Generally, most patients can be cured without surgery. But if there is residual disease after chemoradiation “then they’ll need a salvage neck dissection,” said Dr. Johnson.
On the other hand, some centers are seeing a small return of surgery as robotic surgery and other new technologies arrive, said Bert O’Malley Jr., MD, Professor and Chair of Otorhinolaryngology at the University of Pennsylvania in Philadelphia. There is the question of how much radiation is needed on the primary site if it is given before or after surgery on the neck.
But if the mass is large and firm, there is often a problem with persistent fibrosis, said Dr. Har-El. “We end up doing neck dissection on radiated necks. In those cases, I’d like to do a neck dissection first—then submit the patient to chemo and radiation therapy.”
However, if the oropharyngeal cancer involves the tonsil, this particular location is more radio sensitive than other sites, said Dr. Shaha.
Still, about 15% to 20% of these patients will develop pharyngeal stricture and will require a permanent gastrostomy. Panelists agreed this high rate of stricture leads to a poor quality of life for these patients. “We need something better than just chemoradiation,” said Dr. O’Malley. At the same time, there is still some question about which doses of radiation are most effective, he said.
Treatment Approaches Differ
There was a split in opinion when asked how a 28-year-old female patient with T2 tongue cancer should be treated after partial glossectomy and selective neck dissection with one positive node—observation or radiation therapy. A problem here is that there is a lack of good evidence in terms of what to do, said Dr. Freeman.