Metastases to the lingual nodes in tongue cancer: A pitfall in a conventional neck dissection Mizuo Ando a,b, * , Masao Asai b , Takayuki Ono b , Yukihiro Nakanishi c , Takahiro Asakage a , Tatsuya Yamasoba a a Department of Otorhinolaryngology, School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan b Head and Neck Surgery Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Tyuo-ku, Tokyo 104-0045, Japan c Pathology Division, National Cancer Center Research Institute, 5-1-1 Tsukiji, Tyuo-ku, Tokyo 104-0045, Japan Received 18 May 2009; accepted 6 October 2009 Available online 8 November 2009 Abstract Some classical textbooks of anatomy provided a detailed description of the lingual nodes, which are small inconstant lymph nodes in the floor-of-mouth and the upper neck. The clinical importance of these lymph nodes in cancer therapy, however, has been underestimated so far. We previously reported an extremely poor prognosis of oral tongue cancer patients who had lesions at the root of the lingual artery and assumed that metastases in occult lingual nodes might be responsible for such lesions. This case report clearly demonstrates the distinctive draining course of the lateral lingual nodes, which may potentially be left untreated by a neck dissection. A 63-year-old Japanese male with T2 squamous cell carcinoma of the oral tongue showed multiple metastatic involvements of the lateral lingual nodes; three nodes in close contact with the sublingual gland, and one node at the root of the lingual artery. A systematic inspection of lymph nodes along the draining course of the lateral lingual nodes should be included, because a neck dissection in continuity with the primary tumor (a pull-through approach) is still inadequate for the removal of the lymph nodes at the root of the lingual artery. # 2009 Elsevier Ireland Ltd. All rights reserved. Keywords: Squamous cell carcinoma; Tongue; Neck dissection; Lymph node; Lingual artery 1. Introduction The floor-of-mouth is a delicate region between the primary site and the neck in oral tongue cancer patients. It is not a well-known fact among head and neck surgeons that there have been detailed descriptions of the lingual nodes in classical textbooks of anatomy [1–3]. They are small, inconstant lymph nodes in the floor-of-mouth and the upper neck. Some lymphatic vessels from the lingual and sublingual area are known to run along the lingual artery, often interrupted by the lateral groups of the lingual nodes (lateral lingual nodes), and drain into the deep jugular chain. This means that the lateral lingual nodes are located between the primary site and the neck and that they might be the first echelon nodes in oral tongue cancer patients. Although there have been a few reports describing metastatic lateral lingual nodes in contact with the sublingual gland [4,5], none has clearly described metastasis on their draining course along the lingual artery, i.e. from the sublingual area to the deep jugular chain. This report describes the first case that demonstrated multiple metastatic lymph nodes both in contact with the sublingual gland and along the lingual artery. It is worth noting that the lymph nodes at the root of the lingual artery are beyond the limits of a neck dissection, and thus may potentially be left untreated. 2. Case report A 63-year-old Japanese male presented with a seven- month history of pain in his tongue. On presentation, he had www.elsevier.com/locate/anl Auris Nasus Larynx 37 (2010) 386–389 * Corresponding author at: Department of Otorhinolaryngology, School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113- 8655, Japan. Tel.: +81 3 5800 8665. E-mail address: andom-tky@umin.ac.jp (M. Ando). 0385-8146/$ – see front matter # 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.anl.2009.10.001