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Description
A 63-year-old man with a 20-year history of right torticollis and atlantoaxial rotational deformity (figure 1) presented with complaints of a non-healing painless ulcer over the right lateral aspect of tongue and difficulty swallowing for the preceding 3 months. On examination, an ulceroproliferative growth was noted on the right lateral border of tongue, involving the floor of mouth, outer alveolar border of mandible and crossing the midline without reaching the base of tongue. There was no palpable cervical lymphadenopathy bilaterally. An edge biopsy from the lesion revealed squamous cell carcinoma (SqCC) and a staging workup was initiated. Routine haematological investigations and chest X-ray were normal, however, a direct fibreoptic endoscopy revealed another exophytic growth in the left pyriform fossa (PFS) and a biopsy revealed SqCC. The patient underwent an MRI (face and neck) (figure 2a-b), and the case was discussed in our multidisciplinary tumour (MDT) board meeting. The patient was staged as synchronous dual primary of the head and neck, and each site was staged separately (tongue, cT4acN0cM0, AJCC stage IVa; PFS, cT2cN0cM0, AJCC stage II). The specific issues discussed in the MDT were: (1) appropriate management of the dual primaries; (2) challenges posed by the spinal deformity on intraoperative anaesthesia and postoperative care and (3) difficulties in radiotherapy target delineation due to unusual anatomy.
The management options discussed in MDT were: (1) surgical resection for both lesions; (2) surgical resection of the tongue lesion and definitive radiotherapy to the PFS lesion or (3) definitive chemoradiation to both lesions. Surgical resection of both lesions was excluded due to the extensive nature of the required surgery, and definitive chemoradiation was excluded due to inferior local control rates in oral cavity SqCC.1 The patient underwent a hemiglossectomy, central arch resection and bilateral neck dissection along with an elective suprasternal tracheostomy (prior to the procedure) to facilitate airway management during surgery and the postoperative period. Histopathological evaluation revealed well-differentiated SqCC (depth of invasion 9 mm), with microscopically involved margin (R1 resection) and no involvement of the mandibular bone, lymphovascular invasion, perineural invasion or nodal metastases (0/72 nodes). The final staging was pT3pN0cM0 (AJCC stage III). After an uneventful recovery, he was planned for adjuvant radiotherapy to tongue (based on the risk posed by depth of invasion, pT3 descriptor and R1 resection). Along with delivering adjuvant radiotherapy to tongue, he was also planned for definitive radiotherapy to PFS SqCC.2 Radiotherapy planning was challenging as the patient’s spine deformity precluded standard immobilisation(figure 2C,D) and target delineation was complicated as the unique position meant that delineation guidelines had to be adapted with close collaboration with a diagnostic radiologist (figure 3). Radiotherapy planning and treatment delivery (via Image Guided Volumetric Modulated Arc Therapy) was performed on Varian Eclipse v13.5 and Varian TrueBeam v2.5 (Varian Medical Systems, Palo Alto), respectively.
The patient tolerated treatment well, with Radiation Therapy Oncology Group grade 2 acute mucositis and xerostomia. Two months after treatment completion, the patient achieved a complete radiological response (figure 4) in the PFS primary and has remained recurrence free for 1 year, with no late side effects.
Learning points
Cervical spine deformities are challenging comorbidities to address in the context of modern oncological care and are unfortunately not captured in clinical trials, which explains the scarcity of literature pertaining to their management.
Each case of synchronous dual malignancies has to be evaluated with the intent of preserving functional autonomy and maximising probability of cure, for which a single treatment modality is usually not appropriate.
An advanced radiotherapy technique like Image Guided Volumetric Modulated Arc Therapy (IG-VMAT) is well suited for unconventional cases, ensuring better dose distribution, rapid treatment delivery and improved accuracy when compared with intensity modulated radiotherapy.
Footnotes
Contributors IA is the treating junior consultant (radiotherapy), author of the paper, responsible for drafting the manuscript and revising it. He is the guarantor. RL is the associate consultant (diagnostic radiology), responsible for drafting the imaging-related portions of the manuscript. He also assisted in radiotherapy treatment planning. KSC is the supervising treating consultant (radiotherapy) and participated in article formulation, editing and oversight. SR is the supervising treating consultant (surgical oncology) and participated in article formulation, editing and oversight.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.