A 51-year-old male patient with a history of herniation of the esophageal hiatus, gastroesophageal reflux, hepatitis A in childhood and tonsillectomy.
He comes to consultation, where he mentions that he has "black spots in the tongue" of 3 months of evolution that have increased in number in recent weeks, but that do not produce symptoms.
On physical examination, several pigmented lesions with diffuse distribution, covering 3 × 3 cm from the base of the tongue, were observed.
These lesions are asymptomatic.
There is no trismus, dysphagia or odynophagia.
Lingual mobility is preserved and there are no alterations in tongue sensitivity or taste.
Cervical examination revealed no adenopathies.
At first, due to the appearance of the lesions, it is thought to be the first diagnostic option in vascular lesions.
Despite its "appearing appearance of benignity", incisional biopsy of the lesions is planned.
The latter finally reveals that it is a "mucous melanoma".
Because of the diagnosis, an extension study was carried out, including cervical-facial computerized tomography (CBCT), abdominal computerized tomography (body-CT) and positron emission tomography (PET-CT).
Body-CT is rigorously normal, while PET-CT demonstrates a hypermetabolic focus at the base of the tongue, but discards distant metastatic lesions.
The case is presented in a joint clinical session with radioterápica, surgical treatment.
Surgery began with temporary colostomy.
Next, resection of lingual lesions was performed with safety margins of 2 cm, using a midline cheilotomy and mandibulotomy.
The left lingual artery was preserved to ensure vascularization and therefore the viability of the lingual remnant.
Furthermore, due to the midline location of the lingual base and to reduce the risk of in-transit or occult metastases, prophylactic bilateral functional lymph node dissection was performed.
Finally, the functional reconstruction of the created defect was carried out, allowing the patient to preserve the function voiding and swallowing after subtotalectomy.
Thus, in view of the need to provide volume to the lingual remnant, we opted for anterolateral fasciocutaneous flap of the left thigh, 6 × 6 cm, based on a single perforating branch septocutaneous.
The recipient vessels were the superior thyroid artery and the right lingual vein.
Bilateral aspiration cervical drainages and nasogastric tube (NGS) were placed.
The patient was discharged and admitted favorably.
During his hospital stay, which lasted 8 days, the NGT was removed once he began to swallow and the symptoms were sutured.
The definitive pathological result was reported as "malignant mucosal melanoma, 3 mm from the surgical margin, with an invasive component measured 4.4 mm wide and 2.6 mm deep.
No metastases in cervical lymph nodes or vascular invasion were observed.
Immunohistochemistry showed positive staining for S100 and HMB45, but not for cytokeratins.
The tumor was staged as T3 N0 M0".
Due to the small microscopic margin achieved in spite of the great resection, the case was presented again in a joint clinical session with radiation therapy, adjuvant radiotherapy and immunotherapy.
Thus, 2 weeks after surgical treatment, the patient began radiotherapeutic treatment limited to the base of the tongue, without including cervical region (60 Gypa in single dose periwood-interferon toxicity), which was treated with intraoral radiation therapy.
This regimen consists of a first induction phase with 20 million U/m2 intravenously 5 days a week for 4 weeks and a second maintenance phase with 10 million U/m2 subcutaneously for 11 days once a week.
Currently, 13 months after surgery, the patient is asymptomatic, has no difficulty in metaplasia or metaplasia, and the flap is correctly positioned. There is no evidence of disease recurrence.
