What these notes appear to show

• July 2022: Initial excision/biopsy of a left lateral tongue lesion showed well to moderately differentiated SCC.
• 2024: A local recurrence was treated with left partial glossectomy (removal of part of the tongue) and bilateral modified neck dissection. The note mentions pathological staging around pT?N2 but this should be confirmed from the final pathology report.
• Until May 2024: Adjuvant radiotherapy with chemotherapy was completed, apparently after surgery.
• Late 2025 / early 2026: Another recurrence was seen, initially around 16 x 8 mm on PET-CT.
• PET-CT dated 31 August 2026: The lesion is now reported as roughly 5.5 x 2.7 x 2.8 cm, involving the left anterior two-thirds of the tongue, reaching/crossing toward the midline and extending posteriorly toward the base of tongue. SUVmax is noted as about 19, meaning the lesion is highly metabolically active.
• On clinical examination, the lesion is described as approximately 6 x 4 cm. The notes say there were no clinically detectable neck nodes (cN0), but imaging and final surgical pathology are needed to determine whether microscopic nodal disease exists.
• The proposed plan is TPF chemotherapy for 2-3 cycles, then reassessment for surgery. TPF means docetaxel + cisplatin + 5-fluorouracil, a form of induction/neoadjuvant chemotherapy.

What “NACT/TPF then reassess” means

1. Shrink the tumour if possible.
2. Assess whether it becomes safely removable with adequate cancer-free margins.
3. Treat microscopic disease outside the visible tumour.
4. Help decide between salvage surgery and non-surgical systemic treatment.

Possible management pathways

1. Salvage surgery, if a complete removal is feasible

• A larger partial glossectomy, near-total glossectomy, or total glossectomy depending on exact extension.
• Possible removal of involved floor of mouth/base-of-tongue tissue.
• Reconstructive surgery, often using free-flap tissue from the forearm or thigh.
• Assessment of both sides of the neck, even when no nodes can be felt.
• Temporary airway support, sometimes tracheostomy.
• Feeding-tube support during recovery.
• Intensive speech and swallowing rehabilitation.

2. Induction chemotherapy followed by reassessment

• TPF chemotherapy, usually 2-3 cycles
• Repeat clinical examination and contrast CT/MRI or PET-CT
• A decision on salvage surgery if there is sufficient response and resection remains possible

• CBC, kidney and liver function, electrolytes
• Hearing and neuropathy assessment if cisplatin is planned
• Dental review and infection control
• Nutrition and swallowing status
• Performance status and weight loss
• Prior cumulative cisplatin exposure and prior radiation details

3. Systemic treatment when surgery is not possible

• Pembrolizumab immunotherapy alone if PD-L1 testing shows an appropriate Combined Positive Score (CPS), particularly when a less toxic approach is needed.
• Pembrolizumab plus platinum chemotherapy and 5-FU for appropriate patients needing a higher chance of tumour shrinkage.
• Other chemotherapy-based options, depending on prior drugs, fitness and kidney function.
• Nivolumab or pembrolizumab after progression on platinum-based treatment, depending on the exact treatment sequence and local approvals.

4. Re-irradiation, only in selected circumstances

• The recurrence is not operable or margins are positive after salvage surgery.
• The previous radiation dose distribution permits it.
• The target is limited and treatment can be delivered precisely, such as IMRT or stereotactic techniques.

5. Symptom and supportive management, alongside cancer treatment

• Dietitian and swallowing-therapist review
• High-calorie, high-protein nutrition and early consideration of feeding support if intake is inadequate
• Strong pain control, including treatment for tongue pain and painful swallowing
• Oral hygiene, dental assessment, infection treatment
• Speech and swallowing rehabilitation
• Tobacco, areca nut/gutkha, alcohol cessation if relevant
• Psychological, social and financial support

What should be done urgently

1. Head-and-neck multidisciplinary tumour board review at a cancer center with surgical oncology, reconstructive surgery, medical oncology, radiation oncology, radiology, pathology, dentistry, dietetics and speech/swallow therapy.
2. Review the complete PET-CT report and images, not only the handwritten size. The key question is whether there is any lung, bone, liver, distant nodal, or other spread.
3. Pathology review of the latest tumour specimen, including margins, depth, perineural invasion, lymphovascular invasion, extranodal extension if nodes were involved, and confirmation of SCC.
4. If systemic therapy may be needed, request PD-L1 CPS testing on tumour tissue. Discuss whether additional molecular testing is appropriate.
5. Ask the surgeon a direct question: “Can the entire tumour be removed with clear margins now? If not, what response after TPF would make surgery possible?”
6. Obtain the prior radiotherapy plan and total dose. This is necessary before considering any further radiation.
7. Prompt nutrition review. A feeding tube may be discussed if weight is falling, swallowing is unsafe, or chemotherapy/surgery is expected to make oral intake inadequate.

Questions to take to the oncology appointment

• Is this recurrence considered resectable, borderline resectable, or unresectable?
• Does the PET-CT show disease anywhere outside the mouth/neck?
• What surgery would be required and what speech, swallowing and feeding outcomes are expected?
• Why is TPF preferred before surgery in this specific case?
• What are the chances of response to TPF, and what is the plan if it does not shrink?
• Has PD-L1 CPS been tested? Is pembrolizumab suitable?
• Is re-irradiation technically possible after the prior treatment?
• What nutrition plan and feeding support are needed before treatment begins?