Elective radiotherapy or neck dissection for CT-staged T1-2N0 oral tongue cancer.

To the Editor: The issue of elective treatment for clinically early-stage oral tongue cancer still remains controversial. This is based on the concern that subclinical nodal disease remains a significant feature of early oral tongue cancer, and surgical salvage rates of clinical neck recurrence are often poor. An article entitled ‘‘Prospective trial to evaluate staged neck dissection or elective neck radiotherapy in patients with CTstaged T1–2 N0 squamous cell carcinoma of the oral tongue,’’ written recently by Brennan et al, tried to elucidate the algorithm of elective treatment for CT-staged T1–2N0 oral tongue cancer. This is an important article that provides us with informative prospective data and detailed discussion. However, based on their results, we would like to add some comments to their proposed elective neck dissection and elective radiotherapy (ERT) algorithm. First of all, the thesis of this well-designed study was based on the hopeful goal that management of the node-negative neck in earlystage oral tongue cancer should be by ‘‘singlemodality treatment’’ whenever possible. All the studied patients were dichotomized to either a high-risk group or a low-risk group according to pathological findings of partial glossectomy. The high-risk group patients were defined by primary tongue lesion with 1 or more of the characters including greater than 7 mm muscle invasion, surgical margins less than 5 mm, perineural invasion, and lymphovascular space invasion. The high-risk group patients received ERT (50 Gy) for the neck and adjuvant radiotherapy (60 Gy) for the primary. However, the whole course of treatment for the high-risk group still contains 2 modalities (partial glossectomy and irradiation). In addition, although only surgical treatment was performed for the low-risk group, it was divided into ‘‘2 stages’’ that could cause inconvenience for patients (algorithm 1 of Figure 1). Contrarily, if elective neck dissection was always performed with partial glossectomy and adjuvant radiotherapy was given to risky patients according to overall glossal and cervical pathological findings, the treatment of the low-risk group will still be 1 modality but in only 1 stage (algorithm 2 of Figure 1). Second, if the aforementioned subclinical nodal disease or occult cervical lymph node metastasis is a major concern of early oral tongue cancer, the pathologic N classification should be an important indicator to guide future management. It has been shown in the article of Nyman et al that N classification had a significant association with survival of oral tongue cancer. Some retrospective reviews by Keski-Säntti et al and Huang et al also support the elective neck dissection for early-stage oral tongue cancer. Furthermore, in the article of Myers et al, they found extracapsular spread to be the most significant predictor of both regional recurrence and Head & Neck 32: 1428–1430, 2010 Published online 4 August 2010 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/hed.21525