Management of T3 N2 Squamous Cell Cancer of the Tongue After Hemiglossectomy

Adjuvant Radiation Therapy Parameters

The American College of Radiology recommends delivering 60-66 Gy to the tumor bed and bilateral neck regions using once-daily fractionation of 2 Gy per fraction for T3 N2 tongue cancer following hemiglossectomy 1, 2
Radiation must begin within 6 weeks of surgery to optimize outcomes, as delays beyond this timeframe significantly compromise disease control 1, 2
The tumor bed and bilateral cervical lymph node regions should be treated, with bilateral neck treatment being essential for N2 disease, even if nodes were surgically addressed, due to high risk of microscopic residual disease 2

The National Comprehensive Cancer Network recommends high-dose cisplatin at 100 mg/m² on days 1, 22, and 43 as the preferred regimen (Category 1 evidence) for concurrent chemoradiation in T3 N2 tongue cancer 3, 2
Concurrent chemoradiation provides superior locoregional control and survival compared to radiation alone for advanced-stage disease with N2 nodal involvement, with a significant improvement in disease-free and overall survival in patients with extracapsular spread or multiple positive nodes 3, 4

Positive or close margins (<5 mm) require the full 60-66 Gy dose, and extracapsular nodal extension mandates concurrent chemoradiation at the higher dose range 1, 2, 3
Multiple positive lymph nodes (≥2) indicate the need for aggressive adjuvant therapy, and perineural invasion, lymphovascular invasion, or depth of invasion >4 mm are additional adverse features requiring full-dose treatment 1

If final pathology shows positive margins, >1 mm extracapsular extension, or ≥5 positive nodes, deliver 60-66 Gy with concurrent cisplatin 100 mg/m² 1, 2
Close margins, 2-4 positive nodes, or ≤1 mm extracapsular extension require delivery of 60-66 Gy, with consideration of concurrent cisplatin based on multidisciplinary discussion 1, 2

Delaying radiation start beyond 6 weeks postoperatively significantly worsens locoregional control and survival, and using unilateral radiation fields when N2 disease is present leaves the contralateral neck at risk 1, 2
Underestimating the need for concurrent chemotherapy in N2 disease and failing to deliver adequate radiation dose (60-66 Gy) for T3 disease compromise local control and disease-free survival 1, 2

TSH levels should be monitored every 6-12 months following bilateral neck irradiation, as hypothyroidism occurs in 20-25% of patients, and assess for radiation-induced xerostomia and consider IMRT techniques to reduce salivary gland toxicity 1, 2, 5