A patient presented with a well-circumscribed lesion of her tongue that had been interfering with eating as it grew. After an in-office biopsy that diagnosed it as metastatic breast cancer, Dr. Liana Puscas and her resident perform a partial glossectomy to alleviate the patient’s symptoms.
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- Patient Introduction
- Resection of Lesion
- Measure Lesion Dimensions and Margins
- Specimen Orientation
- Specimen Margins
- Long-acting Local Anesthetic
Do we want to intro our patient here? This may be too big. Do you think a molt would help us out first? No, it’s okay. I think we are good, right there. Can I have something to point with please?
Alright, so you can - this is actually where I took the biopsy from. Before I took the biopsy, it was perfectly round like that, and the interesting thing about it is that you can see it's actually quite well encapsulated. It's not - and it wasn't actually ulcerated. So it was just - I actually was not expecting the diagnosis of metastatic breast cancer. I was actually thinking it was something like a leiomyoma or potentially a small salivary gland tumor that - I was actually expecting something more benign just because of its appearance, but it doesn't have the typical appearance of Swain [1:30]. And it really actually was not painful for her. It - it interfered with her eating a little bit and with her articulation and a little bit, you know, of some pain when you just directly touched it, but in general, it wasn't hurting her.
So - can I see DeBakey's please? I was hoping for something benign, and then it came back as metastatic breast cancer which was… How much of a margin do you want to get around this? I think we can get a centimeter. We need to...
Can I - actually, can I see measuring tape real quick? Let’s get some dimensions on this. And then you can see, she's already had a good blanche of her tongue from where I did the local. A centimeter and a half, and if we are counting where you biopsied, I think about a centimeter and a half all the way around. Yep. And so - so you want to get centimeter margins? Yeah, I think we need to because I’m - I just don’t want this to come back. Okay. I'm - I'm going to just kind of touch in a couple places to give myself a… Can I have a Army-Navy please? I think that's a little close here. Yeah. Go right above the teeth, yeah. Good.
Alright, go for it now. We just start here and work our way around. And then where’s that Army-Navy? Can one of you get the smoke please? Just suck the smoke. Why don't you use - yeah, or just use the towel clamp. This one’s much nicer than that other one. Here’s one. Can I have a rat's tooth? And then here let - now I can pick it up for you. No, you have to hold the smoke. No - get to hold the suction. No, no, not - not you, them. One of the two of them can hold the suction. Can one of you guys hold the suction? And you have a rat’s tooth?
This doesn’t look like it extends deeply, does it? It does not. Doesn't feel like it. I think that’s good. I don’t think you want to go anymore superficial than that though. Okay. And then, watch it. Here’s - here’s your incision on the other side.
Can we make the room cooler please? Suction there. Do you have a bipolar? Who has the pedal?
And you don't need to go any deeper than that cuz if you look a centimeter - yes, just stay - yeah, this way, toward me a little bit. You can take the suction from me please. Thank you. Are you pinning this? Pinning it? Uh, no. Bipolar. Suction. Okay. Will you hold her lower lip out? I don't want her to get burned. There we go. And I just confirm that we're not undercutting on this side.
Do you have a 3-0 or 4-0 silk I can use for marking? I have a 2-0 for my thing. That's fine. So the name of this specimen is left lateral tongue stitch anterior. Yes. Is that for frozen? No, it’s for permanent. Do you want to take frozen margins? I do want to take frozen margins. Okay, can I see DeBakey’s please? Do you just want me to do four quadrants? Yes. And then can I have some Stevens please?
Can you cut this please? No - down here is fine, underneath. Yep.
The first frozen - up, up, up. The first frozen section margin is going to be anterior dorsal. Yes, ma’am. Yes, this is all left lateral tongue. Yes. Here's the specimen. And then, can we get a little rinse please on the instruments? Just some saline or something.
No. These are for fro - there are for frozen section. These are frozen sections. You’ll need to call the research people to come and get whatever they need to from the main specimen. That's usually how they do it. Here's a pair of pickups with teeth. Thank you.
Melissa, the next - the next specimen is gonna be posterior dorsal. Just make sure I don’t have too much char in there. That’s part of it. Just, if you want - take - just call the next one - no, call the next one just posterior. And go from like there to there? Yeah, because we've already done - we - so that way you get the proportion the same. Okay. This next one is going to be left lateral tongue posterior. Get a little rinse on your pickups and instruments. Rinse. So we do that to make sure that any potential malignant cells aren’t contaminating our other specimens.
I’m sorry Melissa - what did you say? Correct. These - this is all left lateral tongue, right? Because that’s the name of the - that’s the name of the specimen. And then we have anterior dorsal, posterior dorsal, posterior. The next one is going to be ventral anterior and then ventral posterior. That’s the rest of the posterior specimen. Correct. Yeah. And then I’ll take a rinse please. And then we have two more. We’ll have ventral anterior and ventral posterior. I’m going to take the anterior first then? Yes.
About right there. Yep, that’s good. This is the ventral anterior specimen. And then a rinse, and then the last one - ventral posterior. Again, all of them left lateral tongue and then just the names of the individual margins. There to there. Okay. This is the ventral posterior - posterior. And then I will see the bipolar please. Suction. Watch her lip. Do you want to close with Vicryls or chromics?
Oh, I think Vicryl is good because it’s a decent size. Just I - I might just do some horizontal mattress sutures just for tensile strength. Do you think that’s ok? Yeah, but that’s why I want to use the Vicryl be - rather than the chromic just because it’s one thing to do it on the - mucosa - on the mucosa - on something that doesn’t move as much, but your tongue moves all the time when you speak and when you’re eating. And so if you want the wound to stay closed, you really need to use something like Vicryl. Cuz unless it’s a very small biopsy, I think the chances are much higher that things will open up if you just use chromic rather than Vicryl.
We can go ahead and close while we’re waiting on frozens? Yes. Can we have the Vicryl please? Do you have a 3-0 Vicryl?
Do you have it on a taper needle? Can I have a pair of DeBakey’s please? Oh hang on, I’m going to use something else. Can I have the Army-Navy again please? Hang on - you want to travel a little more. Yeah that’s it. Thanks. There you go. I’ll come back and get that - that front part. Scissors please.
Why don’t you start up top? It might actually make it easier. You can just backhand it. That way you can sew with the knot on top. Okay. And I think it’ll be easier for you. Sounds good. And plus, I'm thinking, with the knot on top, she doesn’t have any teeth - it won’t bother her as much. Yeah, whereas here it might get involved in the teeth - very considerate - or get caught in between. Well I also don’t want her complaining, “take these out,” before she’s healed. You know, people just tend to play with them all the time when they’re in their mouth.
Now, if we had to do some, you know, very large cancer resection, it would not be worth it. But this is - this is pretty low morbidity. Yeah, she should heal quickly, and this will help her to feel better - especially when you get primary closure on something like this, the pain afterwards isn’t as much as leaving like an open, granulating wound.
Yes - yes, we - cuz it was - it was nice and superficial, so we didn’t have to worry about cranial nerve 12 and injuring that. This lady has a history of metaplastic breast cancer, and it has metastasized to her tongue. So these are just margins. We want to make sure we got it all. I think we did, but… Now, Priya, could she pop up with another lesion in 3 months? Yes, and I think at that point, that's a different conversation.
Can I see another Vicryl please? You don’t want me - do you want me to run anything on the surface at the end or do you just want to leave it like this - kinda everted? I think this will be fine. Okay. I think you need two more - yep - and then the one up front.
It - it’s just the history of it cuz the oncologist is the one who told me. She said that metaplatic - metaplastic breast cancer just doesn't respond very well.
Here let me hold this. Yeah, that’s actually going to be more advantageous.
This was a - this is a first for me. I've taken care of patients with renal cell cancer that has metastasized to the tongue but not breast cancer. You know, Liana, this was actually more common than I was expecting it. Yes, although I - still uncommon but more - more than I expected.
Quite embedded in there. I’ll hang out and wait on the frozens. Can we have some irrigation please? It’s protected. Then can we get some Marcaine please? You just kind of go in and inject along the way back from each side? Yep, all the way around.
We’re now injecting quarter percent Marcaine plain for postoperative analgesia. The Marcaine has a much longer half-life than the lidocaine, and so patients will often do well the day of surgery if you use something long-acting like Marcaine. It works very well for patients who’ve just undergone any kind of oral or oropharyngeal procedures such as tonsillectomy. Maybe a little in the back there. I used five.
Alright, her tongue is a little swollen - I think from the Marcaine and from the lidocaine that we gave her. Yeah, but - she got Decadron preoperatively - yeah, so should be ok. And now what we can do is get her to sit up and that may also help with the - we can - we can lower the bed and then put her in some reverse Trendelenburg. That would be great. And then do we also have some - give it just a second in case we need to get more from somewhere. And then do we have some bacitracin please?