While oral cancer is also called oral cavity cancer or mouth cancer, it is largely caused due to excessive consumption of tobacco, infections in mouth, or a combination of both. The treatment for oral cancer depends on early detection and successful outcomes are possible. One such case was of a middle-aged Iraqi woman with advanced tongue cancer who came to us after having unsuccessful treatments in her home country. This was a challenging case for us which involved salvage surgery (surgery performed after initial treatment has failed) following non-surgical treatment, which also helps us understand the importance of microvascular reconstruction in such cases.
Salvage surgery for head and neck cancers treated with chemo-radiation presents a complex challenge. Treatment with chemo-radiation can alter the local tissue environment, making surgery technically more difficult and potentially increasing the risk of complications.
Initial diagnosis and treatment decisions for oral cancer
In her case, non-surgical treatment failed to achieve complete eradication of tumour. She was checked for extensive tongue involvement that could necessitate total glossectomy (removal of tongue). Removal of tongue can significantly impact functional outcome with regards to speaking, swallowing, and breathing. Hence, this salvage surgery was conducted through proper planning and considering potential complications.
Given the extent of the residual/recurrent cancer, a total glossectomy with bilateral selective neck dissection was planned.
Microvascular reconstruction was performed
In addition to the tongue removal surgery, a reconstructive microvascular surgery using a free flap from the thigh was performed to restore the functional abilities of the mouth post-surgery.
Microvascular surgery for oral cancer treatment involves using a flap (like skin with fascia/muscle/bone) of varying composition and size with its blood vessels from any distant part of the body. In this case, a large flap (skin with fascia and some muscle) was taken from her thigh, along with its artery and vein (pedicle). This flap was then transferred to the area where the tongue was removed and stitched to the surrounding tissues and the vascular pedicle was connected to the recipient blood vessels in the neck using microsurgical techniques. Establishing blood flow/revascularization to local vessels was crucial for successful reconstruction.
Following reconstructive surgery, she required additional procedures at the same time to support her breathing and swallowing due to the loss of her tongue. These included:
Laryngeal Suspension
A procedure where special stitches are used to lift the voice box (larynx) by connecting it to the bone under the jaw. This helps prevent food or saliva from going into the airway.
Tracheostomy
This is when a tube is put into the front of the neck to help with breathing. It’s used temporarily when the normal breathing path isn’t working well.
Feeding Tube
It’s a tube put into the stomach either through the nose or through a small cut in the belly. This tube helps provide food and nutrition when someone can’t eat normally.
About 5-6 weeks post-surgery, the woman showed significant functional improvement. She successfully regained her swallowing, speaking, and breathing abilities. Both the breathing tube and feeding tube were then removed.
This individual has improved quality of life and remained disease-free for the last five years post her salvage surgery. This case demonstrates the success of salvage surgery with microvascular reconstruction for advanced tongue cancer, even in individuals previously treated with non-surgical methods, ensuring good oncological and functional outcome.
-As told to Ipshita Ghosh
The author is a consultant in the department of Head & Neck Oncology, Aster CMI Hospital, Bangalore
