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Tongue Reconstruction Helps Soldier

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BOSTON, Mass. (Ivanhoe Newswire) - Imagine losing your tongue to a disease. Every year about 30,000 people develop cancers of the mouth, and it most often affects the tongue. Now, doctors are using new surgical techniques that help turn another body part into a replacement tongue.

Captain Greg Page decided to enlist in the National Guard after September 11, 2001, but the battle of his life would begin with a painful sore under his tongue.

"I find out it's squamous cell carcinoma," said Greg.

About half the people with this deadly type of cancer will die in five years.

"It's almost like I felt like I'm marching in to a battle, because here I am coming to fight this thing," he said.

The cancer was so big, Dr. Derrick Lin, Associate Professor at Harvard Medical School, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, would have to remove about half of Greg's tongue.

"In the past, we'd just leave that alone and what would happen was this edge would seal down to the bottom of the mouth, so it becomes tongue tied like this," Dr. Lin told Ivanhoe.

This would make it hard to swallow or even speak, something this military intelligence officer couldn't imagine.

"Definitely a lot of that job is briefing. A lot of it is public speaking and to think that I'm going to lose a big part of my tongue and not be able to do that is pretty scary," said Greg.

Instead, Dr. Lin used a new reconstruction approach. After the cancer was removed, he took tissue from Greg's forearm.

"It's connected to a vein from the arm. It's brought up to the tongue, recreating the tongue and the aortic veins are reconnected in the neck," said Dr. Lin.

The new technique cut surgery time from 24 hours to 6 hours, and hospital stays went from 21 days to 7 days. The surgery helped Greg talk and swallow normally.

Something unusual reminds him how unique his tongue reconstruction really is.

"You can see the hair there. That's his forearm," said Dr. Lin.

This is a strange side-effect that this soldier who knows things could have been much worse can definitely live with. Hair on a patient's reconstructed tongue can be removed, but Greg has chosen not to do it at this point.

The majority of people coming to see Dr. Lin for oral cancer are over age 70. Now that surgery times have been so dramatically reduced, tongue reconstruction can be offered to patients up into their 90s.

RESEARCH SUMMARY

BACKGROUND: Squamous cell carcinoma is a type of skin cancer. Skin cancer falls into two groups: non-melanoma and melanoma. Squamous cell is a type of non-melanoma skin cancer. Tongue cancer is a subgroup of head and neck cancer. Cancer develops from the squamous cells of the tongue. This leads to a local tumor growth, and it later spreads. Tongue cancer is often grouped with other mouth cancers, such as cancer of the lips, hard palate, cheek lining, floor of the mouth (portion of the mouth underneath the front of the tongue), or gums. These cancers are collectively known as oral cavity cancer.

SYMPTOMS: Squamous cell skin cancer usually occurs on the face, ears, neck, hands, or arm. It may occur on other areas. The main symptom is a growing bump that may have a rough, scaly surface and flat reddish patches. The earliest form appears as a scaly, crusted, and large reddish patch (often larger than 1 inch). A sore that does not heal can be a sign of squamous cell cancer. Any change in an existing wart, mole, or other skin lesion could be a sign of skin cancer. (Source: http://www.ncbi.nlm.nih.gov/)

TREATMENT: Most very small cancers of the oral tongue can be quickly and successfully treated by surgical removal leaving behind little cosmetic or functional change. This is not always true, however, as there can be many variables and factors that can seriously impact speech and swallowing. Larger cancers may indeed have some effect on speech and on swallowing, but one must remember that not treating this problem would cause far more significant problems, up to, and including death. (Source: http://www.tonguecancer.com)

NEW TECHNOLOGY: The new tongue reconstruction surgery includes removing a portion of the tongue and reconstructing the new tongue, is long and complex, lasting about 10 hours. It requires surgeons to dissect and reattach the blood vessels, just like with a typical organ transplant. The blood vessels are sewn together with tiny sutures, some smaller than a single strand of hair. When patients wake up, their reconstructed tongue is in place. (Source: http://www.news-medical.net)

INTERVIEW

Derrick T. Lin, MD, FACS, of the Massachusetts Eye and Ear Infirmary, talks about doctors are using new surgical techniques that help turn another body part into a replacement tongue.

Who is at risk for Oral Cancer?

Dr. Lin: The risk factors are smoking, alcohol use and now human papilloma virus, which are the biggest culprits for it. But there are rare exceptions to the rule where people have no risk factors and still develop this cancer. In general, people who don't smoke, don't drink and do not have human papilloma virus, should not be at high risk for this cancer. But vigilance is always important if someone has a sore in their mouth that just doesn't heal.

Can you tell me about when you first saw Greg? What was he diagnosed with?

Dr. Lin: We first saw him back in 2010, at which point he had a ulcer on his left lateral tongue and that ulcer was already biopsied prior to seeing us. It was positive for invasive squama cell cancer, which is the most common type of cancer in the oral tongue. Because of its size, we knew that if surgery was to be contemplated, it would mean some type of reconstruction to give him his best chance of speaking and swallowing well again and that's what we offered him.

Tell us about this procedure.

Dr. Lin: We do a lot of it, I should say. With experience we we're able to reconstruct people better and better each passing year. With Greg's situation, he had a tongue cancer that required taking about forty to fifty percent of his tongue and that needed to be reconstructed. Thirty years ago we did not have the technology to rebuild a tongue in that fashion and people were just left with half a tongue. With half a tongue people still did okay, but their speech and swallowing was certainly not as well as it could be today. With reconstruction we're able to recreate a tongue, and what we did for him was borrow tissue from his forearm and recreated a tongue that allows him to speak and swallow well again.

There's no further need for radiation and additional treatment correct?

Dr. Lin: Part of his not needing radiation is not only the surgery that we did but the pathology, meaning that he was in a favorable group. Part of it is him and part of it is the surgery. There are things that we can't control. If he had cancer in his neck that we found at the time of surgery, then we would still offer radiation after surgery. The first thing is good surgery, and what is good surgery? It's wide margins, taking the cancer out with a good one to one and a half centimeter margin of normal tissue so we know that we are completely clear around it. It's also removing the lymph nodes in his neck to make sure that his cancer has not traveled to his neck. Those two combinations allows us to offer him not doing any more therapy. Now the only way to get a wide margin is to be able to rebuild it. If we did not have the technology to rebuild it, we would say, well let's try to cut corners here and there to try to give him a good quality of life and let radiation resolve the rest. Our ability to reconstruct allows us to remove adequate tissue so that radiation is not necessary.

What are the pitfalls of radiation?

Dr. Lin: From our standpoint, most of our patients always tell us the surgery was a lot easier than the radiation. The main side effects of radiation are dry mouth, dry throat, and a proportion of people will need a feeding tube lifelong. Radiation for its credit does some wonderful things as well, like cures cancers sometimes in areas that we cannot surgically remove. There are plus and minuses to any treatment that you offer. In Greg's particular case with an oral cavity tongue cancer the ability to avoid radiation to his tongue was very helpful in his recovery.

What is it that separates what you do here from what everybody else is doing? How does that compare to the typical surgery?

Dr. Lin: The reconstruction that we do is not just simply putting a graft in there. The reconstruction is a full thickness graft from the forearm. It's connected to an artery and vein from the arm and it's brought up to the tongue, recreating the tongue and the artery and veins are reconnected in the neck. The artery and vein are small; they're about the size of a pin. We do it underneath the microscope and it's called microvascular surgery. We do a fair amount of it here, but it allows one to regain function of that tongue.

How long have you been doing this type of surgery?

Dr. Lin: For about nine years.

How has it evolved and changed in that nine years?

Dr. Lin: Twenty years ago this technology was not there. It really took shape over the last ten or fifteen years. What it has allowed us to do is be able to give people better quality of life who have been afflicted with head and neck cancer. What has changed over time is our ability to understand how to reconstruct safely. When this type of reconstruction first started, it used to take about twenty four or twenty five hours. Now we're able to do it in about six hours, which is quite a bit difference of time. The success rate for living is much higher now. We, at this institution, have about ninety eight percent success rate. It helped us all in understanding how these reconstructions work and learning how to avoid pitfalls.

What percentage of patients would you say are seventy or older?

Dr. Lin: Most of my patients are over seventy. Fifteen years ago most of us would have declined of doing this type of surgery on them because we would say; well you may not make it through hours of anesthesia. But now that we're able to do this, much more safely and efficiently we're able to offer this surgery to even patients in their nineties which I have done. I think the fact that we have a specialty hospital allows us to do this more frequently and with a little bit of a higher success, because this is what we do.

How can we fight cancer? Are we ever going to be able to avoid it?

Dr. Lin: I think our bodies are constantly fighting cancer. I think you form a balance. I'm not saying this to scare everyone. I think what happens is ninety nine point nine percent of the time a small cancer forms in your body and your body just destroys it, your immune system destroys it. I think you're in this constant flux of fighting off these things that are trying to get you. Then all it takes is that one thing to hold, catch and hold on and that's what forms the cancer. We have this hemostasis between us and our body to try to fight off things that keep on rising. Ninety nine point nine percent of the time we fight it off just fine.

FOR MORE INFORMATION, PLEASE CONTACT:

Mary Leach
Director of Public Affairs
Mass. Eye and Ear
(617) 573-4170
Mary_Leach@meei.harvard.edu

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