1. Introduction

a. Measure Lesion Dimensions and Margins

b. Resection

c. Specimen Orientation

2. Resection of Lesion

3. Specimen Margins

4. Hemostasis

5. Closure

6. Long-acting Local Anesthetic

Jaw and oral cavity involvement by metastatic disease is very rare, occurring in less than 1% of all oral malignancies. Unfortunately, oral metastasis is usually a manifestation of an advanced stage of primary cancer and indicates widespread disease and poor prognosis.

In this clinical case, a patient presented with a left breast lump and a well-circumscribed lesion on her tongue, causing interference with eating as it grew. Despite its benign appearance, an initial in-office biopsy was performed. Further investigations included a mammography that revealed an irregular mass in the upper outer quadrant of the breast, along with enlarged ipsilateral lymph nodes. Contrast-enhanced CT scans further showed a lesion on the right side of the tongue, a left breast lump, and spinal metastasis. Osteoscintigraphy confirmed multiple bone metastases. Subsequent breast core biopsy results indicated invasive ductal carcinoma, and the tongue biopsy revealed an unexpected diagnosis of metastatic lesion secondary to breast cancer. Hormone therapy was initiated, and the patient underwent a palliative partial glossectomy.

<h4>CHAPTER 1</h4>

<p>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.
Okay, can I see...
Can I have something to point with please?
All right, 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. 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…</p>

<h4>CHAPTER 2</h4>

<p>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, that's better.
Much better. Yeah.
Go right above the teeth, yeah. Good.
All right, go for it now.</p>

<p>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 - you have 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? Okay.
It doesn’t look like it extends deeply, does it? It does not.
It 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... A centimeter deep?
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...
That's fine.</p>

<p>So the name of this specimen
is left
lateral tongue
stitch anterior.
Left lateral tongue, stitch anterior. Yes.
Is that for frozen?
No, it’s for permanent. 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?
Thank you.
Can you cut this, please?
No - down here is fine. Right here?
Uh, underneath.
Yep.</p>

<h4>CHAPTER 3</h4>

<p>The first frozen -
The first frozen section margin
is going to be anterior dorsal.
Yes, ma’am. Yes, this is all left lateral tongue.
Let me get her lip out of the way. Yeah, thank you.
Can I take this? Yes.
Anterior dorsal tongue, left, for frozen.
Here's the specimen.
And then,
can we get a little rinse, please, on the instruments?
Just some saline or something.
Is that frozen or research?
No. These 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.
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 we'll 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?
So I have posterior dorsal, left tongue,
then left lateral tongue, posterior.
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.
Posterior. Correct.
Yeah. And then I’ll take a rinse, please.
And then we have two
more. We’ll have ventral anterior and ventral posterior.
Okay.
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. Posterior. This is the ventral posterior.
And then I will see the bipolar, please.
Suction.
Watch her lip.</p>

<h4>CHAPTER 4</h4>

<p>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
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.
Because 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?</p>

<h4>CHAPTER 5</h4>

<p>And 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 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, Dr. Puscas. 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
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.
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 to -
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’s just the history of it cuz the oncologist is the one who
told me. She said that metaplastic breast
cancer just doesn't respond very well. Here, let me hold this.
Yeah, that actually can 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.
I noticed in the literature that this was actually more common
than I was expecting it. Yes, although I - me too.
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. Thank you.
Then can we get some marcaine, please?</p>

<h4>CHAPTER 6</h4>

<p>You just kind of go in and inject along the way back
from each side? Yep, all the way around, yep.
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.
Okay. Okay.
I used five.
All right, her tongue is a little swollen -
I think from the marcaine and from the
lidocaine that we gave her. Yeah, she got
Decadron preoperatively. Yeah, so should be okay.
And now what we can
do is get her to sit up and that may also help with the...
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?</p>


Watcht this full-length, narrated surgical video of a partial glossectomy for a metastatic tongue lesion.

DOI
Publication Date	2024/04/19
Article ID	209
Production ID	0209
Volume	2024
Issue	209
https://doi.org/10.24296/jomi/209

Partial Glossectomy

Procedure Outline

Table of Contents

1. Introduction

2. Resection of Lesion

3. Specimen Margins

4. Hemostasis

5. Closure

6.Long-acting Local Anesthetic