Chapter 18

### The Patient's Story

Mr K is a 57-year-old financial analyst with a long history of precancerous and cancerous oral lesions. Although his medical history includes hypertension, diabetes mellitus, and human immunodeficiency virus infection (well controlled with antiretroviral treatments), he has no risk factors for oral cancer, specifically no tobacco use, or significant alcohol intake. Twelve years ago, he developed a tongue lesion that demonstrated dysplasia. It was treated with topical steroids and then both laser and surgical excision. The lesion recurred 2 years later, and a biopsy specimen revealed superficially invasive well-differentiated squamous cell carcinoma. He underwent wide resection with all margins clear of carcinoma but with residual dysplasia at the edges.

He was followed up closely, and 7 years after initial diagnosis he began experiencing worsening tongue pain. A biopsy specimen at this time showed recurrence of his squamous cell carcinoma. He was then referred to Dr U, who performed a right partial glossectomy and ipsilateral neck dissection. Pathological analysis of the tongue specimen revealed carcinoma extending to the lateral margin. At this point, mandibular resection and reconstruction with a free fibula flap were undertaken. Intraoperative frozen section margins did not show evidence of cancer, but on final pathological examination, however, there was extensive involvement of the mandible to the lateral margin. Mr K was taken back to the operating room for a third resection and reconstruction with a second free fibula flap. After the operation, he underwent radiation therapy to the neck. Currently, 3 months after completion of radiation therapy, he appears to be free of disease.

During his operations and radiation therapy, Mr K lost nearly 20 lb. He remains dependent on liquid artificial hydration and nutrition, delivered through a gastrostomy tube. He has difficulty controlling his oral secretions. His speech is intelligible but significantly different from his former pattern. The significant pain he experienced from the radiation therapy, including burns around the chin and neck, ulcers on his lips, and bleeding in his mouth, have all abated. He has returned to his work as a financial analyst part time and is able to live independently and support himself.

### Perspectives

Mr K and Dr U were interviewed by a Perspectives editor 3 months after completion of Mr K's radiation therapy.

MR K: I had followed up with my surgeon's associate once or twice a year and was disappointed to find that the cancer had returned last year. Over the years, once in a while, they had done biopsies, but they always came back negative; this time it was positive. When I had the earlier surgery in 1999, it affected my ability to speak and eat normally. I also had concerns about the pain involved in recovering from the surgery. This time the surgery was much more extensive. I had 3 successive surgeries this time. After the second surgery, the postoperative tests revealed that there ...

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