Thyroid as a target of metastases: a case of metastatic seminoma in a patient who died of a second cancer.

BACKGROUND: The typical route of metastatic spread of testicular seminoma is through lymphatic pathways, whereas hematogenous dissemination is less frequent. The thyroid is a rare site of metastases from any cancer, but any patient with a previous oncologic disease should inquire about a thyroid nodule. CASE REPORT: We present a case of a 37-years-old man with a testicular seminoma with a peculiar metastatic spread behavior, with previously unreported histological findings. The initial clinical appearance was of a stage I testicular tumor with normal tumor markers. Nevertheless, the tumor appeared to have spread directly to the thyroid gland and subsequently to latero-cervical nodes, about 3 years after the first diagnosis. Perhaps the patient could have been treated with chemotherapy alone, as he developed a second cancer 6 years after the diagnosis, and that event could have been related to delivered therapies, mainly radiotherapy. CONCLUSION: This type of seminoma spread has previously been described only once, and it is not a typical route for metastasis by seminoma. In view of this unusual finding, we reinforce the need for accurate diagnostic planning of any thyroid nodule occurring in a patient with a previous cancer history. Accurate staging is crucial in planning the treatment and follow-up of seminoma. Currently, greater attention is due to management of the disease at diagnosis, as emerging data support a risk of a second cancer among patients treated with radiotherapy and chemotherapy for a testicular cancer.

Thyroid as a target of metastases. A case of foregut neuroendocrine carcinoma with multiple abdominal metastases and a thyroid localization after 21 years.

The thyroid gland is quite often the target of metastases. For this reason any thyroid nodule in a patient with a previous history of cancer needs to be evaluated. In case of thyroid metastases, the site of the primary tumor is most often the breast, lung or kidney. A thyroid metastasis from a foregut neuroendocrine tumor is very unusual and requires a differential diagnosis with primary neuroendocrine tumor of the gland itself, i.e., a medullary thyroid carcinoma. This case report is peculiar because of the multiple sites of abdominal relapses, the long time interval between relapses (21 years), and the positive outcome after surgical treatment.

Papillary carcinoma of the thyroid gland of childhood and adolescence: Morphologic subtypes, biologic behavior and prognosis: a clinicopathologic study of 42 sporadic cases treated at a single institution during a 30-year period.

Papillary thyroid carcinomas (PTCs) in pediatric age show an excellent outcome, independently of sex, stage at diagnosis, occurrence of relapse, and type of treatment. Our aim was to study the biologic behavior and the impact on survival of PTC subtypes in childhood. From 1968 to 2002, 42 sporadic pediatric PTCs were subclassified into PTC, not otherwise specified and PTC variants. In all cases, sex, age at diagnosis, age of menarche, side, size, TNM/pTNM classification, neoplastic microfoci, vascular invasion, status of the non-neoplastic parenchyma, and treatment (surgery and nonsurgical therapies) were registered. Follow-up was carried on up to May 2005. PTC, solid/trabecular variant was the most frequent subtype. Both extrathyroid local invasion (P < 0.04) and distant metastases (P < 0.01) at onset were significantly associated with PTC, not otherwise specified. After a median follow-up of 16 years, for the whole series overall survival and progression-free survival (PFS) rates were 100% and 77%, respectively. The solid/trabecular variant was at a significantly increased risk of relapse (PFS 50%, P < 0.01). The occurrence of poorly differentiated tall cell morphology did not influence survival. Sensitivity to hormonal manipulation was maintained over time. In conclusion, although overall survival was not influenced by PTC subtypes, the solid/trabecular variant of PTC was at a significantly higher risk of relapse. At variance with adults, presence of the tall cell morphology did not carry a worst prognostic significance.

Epithelioid angiosarcoma of the thyroid gland without distant metastases at diagnosis: report of six cases with a long follow-up.

We present six cases of epithelioid angiosarcomas (EAS) of the thyroid gland without distant metastases at diagnosis and with a long follow-up. We retrieved the six consecutive cases of thyroid EAS between 2005 and 2011. Gender was equally represented; median age was 60 years (range 53-68). One case was post-irradiation and another post-exposure to vinyl chloride. Median diameter was 6 cm (range 5-13). Regional nodal metastases were present at onset in two cases. All the cases expressed CD31 in a membranous pattern. CD34 was always negative. All the patients underwent complete surgical resection. Neoadjuvant chemotherapy was applied in one case and adjuvant chemotherapy in four cases with adjuvant radiation therapy in one case. Follow-up until June 2015 was available in five cases. Median follow-up was 59 months (range 9-82). Three patients relapsed. Two patients (the post-irradiation and post vinyl chloride exposure cases) died of disease after 36 and 9 months, after a local relapse soon followed by distant metastases. Three patients are alive and well after 59, 70, and 82 months, including a patient with a relapse treated with neoadjuvant chemotherapy and surgery. In conclusion, thyroid EAS without distant metastases at diagnosis are very rare tumors. They all expressed CD31, while CD34 was always negative. Distant metastases developed together with local relapse, rapidly followed by death. Inadequate surgery contributed to poor outcome. Cases with previous exposure to irradiation and vinyl chloride showed a particularly poor behavior.

Recombinant human thyrotropin (rhTSH) in the follow-up and treatment of patients with thyroid cancer.

The follow-up of thyroid cancer is based on the detection of residual and recurrent thyroid carcinoma. This is traditionally done by means of measurements of serum thyroglobulin (Tg) combined with various imaging techniques (131I-whole body scan, ultrasound and other modalities). Tg serum levels and the uptake of 131I on a whole body scan (WBS) depend on TSH stimulation, which in thyroidectomized patients can be obtained either by withdrawal of thyroid hormone treatment (thyroxine) or by administration of exogenous TSH. At present exogenous human TSH is obtained by means of recombinant DNA technology, (recombinant human TSH (rhTSH), Thyrogen). Even if the administration of rhTSH and withdrawal of thyroid hormone are not completely equivalent, the use of rhTSH has already entered the clinical routine (rhTSH Tg test and rhTSH WBS) because with rhTSH the morbidity and discomfort associated with the withdrawal of thyroid hormone can be avoided. At a recent International Consensus Conference on the follow-up of differentiated thyroid carcinoma it was proposed to carry out only Tg measurement after rhTSH stimulation; moreover, it was stated that 131I whole body scan has to be discouraged in patients submitted to radical surgery and radioiodine ablation with no clinical evidence of residual tumor and with undetectable levels of Tg during hormonal suppression of TSH. Similar strategies in this respect tend to eliminate the 131I WBS and propose only the rhTSH Tg test combined with head and neck ultrasound (US). This is still a matter of debate, also because it is not valid for all risk groups and not all patients undergo the same clinical management (radical surgery or not, thyroid ablation with 131I or not). However, the availability of rhTSH will definitely change the management of papillary and follicular thyroid carcinoma, also with regard to iodine treatment. In fact, rhTSH can be used during radioiodine treatment to enhance the 131I uptake by the cancer cells in particular groups of patients. Patients who could benefit from this approach can be divided into three subgroups: 1) patients in whom thyroxine withdrawal may be dangerous because of the effects of long-term TSH stimulation on the tumor mass (brain metastases, vertebral metastases, presence of neurological signs, heart diseases); 2) patients affected by tumors with marked biological aggressiveness and a low iodine uptake (variants of follicular carcinoma, insular carcinoma, tall and columnar cell variants of papillary thyroid carcinoma, Hürthle cell carcinoma); 3) patients with hypothalamic-pituitary alterations. The potential efficiency of rhTSH in radiometabolic treatment is an important issue that has been studied in a limited number of patients, but is worthy of further investigations in large perspective. A recent clinical prospective trial has been proposed by the Thyroid Cancer Study Group of the Istituto Nazionale Tumori and is now ongoing.

Prophylactic thyroidectomy in MEN 2A syndrome.

Genetic testing is the appropriate procedure in MEN 2A syndrome for the early diagnosis of medullary carcinoma even at a preclinical stage. Prophylactic total thyroidectomy represents the standard preventive and therapeutic surgical approach in the treatment of medullary thyroid carcinoma in MEN 2A syndrome. Our experience has confirmed the presence of CCH and medullary thyroid carcinoma even in clinically negative patients, in agreement with reports in the literature.

Diagnostic procedures in the follow-up of patients affected by MEN type 2.

Multiple endocrine neoplasia type 2 (MEN 2) is an inherited disease caused by germline mutations in the RET proto-oncogene. The most distinctive MEN 2 variants are MEN 2A, MEN 2B and familial medullary thyroid cancer (FMTC). The hallmark of these syndromes is the development of medullary thyroid carcinoma (MTC), which occurs in almost all patients with MEN 2 syndromes. Other endocrinopathies are variably expressed. Pheochromocytoma and hyperparathyroidism occur in patients with MEN 2A with a frequency of about 50% and 30%, respectively. In this paper we summarize the most relevant diagnostic methods to detect and monitor MTC, pheochromocytoma and hyperparathyroidism.

Tall cell variant of papillary thyroid carcinoma in children: report of three cases with long-term follow-up from a single institution.

Papillary thyroid carcinoma (PTC), tall cell (TC) variant, is exceptional in children. In adults it represents about 20% of PTCs, featuring a high-risk neoplasm, with a 4-fold risk of relapse and a 20-fold relapse-related risk of death. Out of 42 cases of pediatric PTCs, we found 3 cases of PTC-TC (7%) with clinical data at onset and follow-up up to June 2014. They were 3 females aged 13, 15, and 15 years. Local extrathyroid extension was present in 2 cases. Neither nodal nor distant metastases were found. Two patients underwent hemithyroidectomy and 1 patient a total thyroidectomy, followed in all cases by life-long suppressive hormonal therapy. On follow-up, the patients were alive and well after 29, 24, and 29 years, respectively. The rarity of PTC-TC in children was confirmed. The behavior was indolent after a median follow-up of about 29 years, following treatment with hemithyroidectomy in 2 cases and controlled by suppressive hormonal therapy. The results of this series, albeit small, suggest that TC morphology in PTC does not carry the same negative prognostic significance in children as it does in adults. A conservative approach should therefore be considered for these 'pediatric type' cases of this tumor type.

Neoplastic lymphangiosis of the upper aerodigestive tract simulating field cancerization: histopathological analysis, surgical limits and literature review.

Neoplastic lymphangiosis is defined as extensive embolic spread of cancer cells in the lymphatic vessels often without any evidence of a mass. Instead, field cancerization is defined by the presence of multifocal neoplastic lesions in a mucosal field previously exposed to mutagenic factors. In this case report, this oncological entity was suggested by the wide extent and multifocality of the disease and by the patient's exposure to risk factors. Instead, the pathological slides revealed the integrity of the mucosa and the presence of widespread embolic metastasis to lymphatic vessels. Thus, the diagnosis was changed to neoplastic lymphangiosis. This clinical presentation is a negative prognostic factor, and surgical treatment is ineffective because of the impossibility to obtain adequate free margins. The present case underlines the poor prognosis of such locally advanced cancer and the importance of recognizing it early so that the treatment approach can be adapted.

Radiation-induced thyroid changes: a retrospective and a prospective view.

AIM OF THE STUDY: Incidental/therapeutic thyroid irradiation causes hypothyroidism and nodular disease. Increasing numbers of children are being cured of cancers by treatments that include radiation also involving the thyroid bed: these children warrant an early diagnosis and treatment of any radiation-related thyroid changes. METHODS: In 1998 we retrospectively evaluated thyroid parenchyma/function in all patients irradiated between 1975 and 1997; thereafter, we prospectively evaluated all patients given thyroid irradiation by means of thyroid ultrasound and serum fT3, fT4, TSH and thyroglobulin. RESULTS: Of 596 eligible patients, 468 agreed to the retrospective evaluation: 128/468 had one or more thyroid nodules, and 73 of these 128 had concomitant or previously untreated hypothyroidism, while 22/128 had a differentiated carcinoma. Another 144/157 patients treated between 1998 and 2004 were evaluated and any iatrogenic hypothyroidism was promptly treated: 19/144 had nodules, all smaller than 1cm in diameter. The first patient group was studied retrospectively, so we have no precise record of the time of nodule occurrence or of their initial sizes. We found, however, that both the number of patients with nodules and the sizes of the nodules were significantly lower (p<0.01) in the prospectively studied group (after a median follow-up of 81 months) than in the retrospectively studied group. Among all the patients with nodules, significantly more females developed cancer than males (p<0.04). CONCLUSIONS: Early treatment for hypothyroidism and ultrasound evaluation of the parenchyma are needed to limit nodule onset and growth.

Treatment of sporadic nonmedullary thyroid carcinomas in pediatric age.

Nonmedullary thyroid carcinomas are rare malignancies in pediatric ages. The vast majority of them are papillary carcinomas with an overall survival of approximately 100%. Their outcome is independent of strong prognostic factors of adults, such as papillary carcinoma histological subtype, invasion into soft tissue of the neck, presence and site of distant metastases, relapse and type of surgery. In these ages, follicular carcinomas and poorly differentiated carcinomas are exceptional. Undifferentiated (anaplastic) carcinomas are practically absent. In most institutions, the therapy of choice for all pediatric thyroid carcinomas is the radical approach, aimed at the eradication at diagnosis of all clinical and subclinical neoplastic foci, both at thyroid, lymph node and distant level. It consists of total thyroidectomy and lymphadenectomy in children with clinically evident lymph-node metastases, followed by radioactive iodine therapy independent of histotype and stage. Recently, owing also to the high sensitivity to hormonal manipulation shown by pediatric papillary carcinomas, a conservative approach has been proposed for selected cases, consisting of the removal of only the grossly detectable disease followed by thyroid-stimulating hormone-suppressive hormonal therapy to control subclinical disease. Today, the existence of two therapeutic approaches, radical versus conservative therapy, should be considered whenever treating a child or adolescent with a nonmedullary thyroid carcinoma. Not least, permanent post-treatment complications of radical surgery and radioactive iodine therapy should be taken into account. The future tasks include the stratification of thyroid carcinomas into low- and high-risk cases, also including their molecular alterations and the possibility of a molecularly targeted therapy against tyrosine kinases involved in the pathogenesis of thyroid carcinomas.

Thyroid carcinoma associated with squamous cell carcinoma of the head and neck: which policy?

BACKGROUND: Thyroid carcinoma occurring as a second primary associated with head and neck squamous cell carcinoma (HNSCC) is unusual. The clinical management of thyroid cancer in such cases has been debated. METHODS: Between 1975 and 2004, we collected 33 cases. The associated thyroid carcinoma was diagnosed either during or as a consequence of surgery planned as head and neck cancer treatment. RESULTS: The associated thyroid carcinoma was never seen to recur. Five-year overall survival was 41%. Disease-free survival after 40 and 66 months was 11.1% and 5.6%, respectively. CONCLUSIONS: We consider the treatment of thyroid cancer to be complete when the thyroid gland, either with or without lymph nodes, has been included in the specimen obtained during surgery for HNSCC. In the group of cases in which associated thyroid carcinoma was only found within the neck lymph nodes and the thyroid gland has not been treated, we discourage further surgical treatment or radioactive iodine therapy.

Feasibility and efficacy of percutaneous transcatheter intraarterial chemotherapy with paclitaxel in albumin nanoparticles for advanced squamous-cell carcinoma of the oral cavity, oropharynx, and hypopharynx.

PURPOSE: In view of the promising results of a phase I trial, this phase II trial was conducted to study the efficacy and safety of intraarterial induction chemotherapy with a novel nanoparticle albumin-bound paclitaxel formulation in advanced head and neck cancer. MATERIALS AND METHODS: Sixty previously untreated patients with locally advanced squamous-cell carcinoma (SCC) of the oral cavity, oropharynx, or hypopharynx in stage T3/4 and any nodal stage received two to four cycles of nanoparticle albumin-bound paclitaxel by infusion into the external carotid artery or one of its branches, without premedication, at an initial dose of 230 mg/m2 and subsequently a reduced dose of 150 mg/m2. Response was evaluated by physical examination and multidetector computed tomography in all patients, and also by positron emission tomography with [18F]fluorodeoxyglucose in 38 patients. Definitive treatment was surgery, chemotherapy, radiation therapy, or chemoradiation therapy. RESULTS: Intraarterial chemotherapy had a low incidence of complications and produced complete or partial responses in 45 of 60 treated patients (75%). Seven patients (11.67%) had stable disease and eight (13.33%) had disease progression. High-grade bone marrow depression was rare. An unexpected toxicity was reversible facial nerve palsy on the side of infusion, which occurred in six patients at initial dosage. Reduction of the dose eliminated this specific toxicity without any loss of efficacy. CONCLUSION: The promising response rates and tolerability of intraarterial chemotherapy with nanoparticle albumin-bound paclitaxel justify further investigation of this formulation, alone or in combination with other agents, in advanced SCC of the head and neck.

Salivary gland neoplasms in children: the experience of the Istituto Nazionale Tumori of Milan.

BACKGROUND: Epithelial salivary gland tumors are very uncommon in pediatric age. We report a series of 52 cases treated at the Istituto Nazionale Tumori of Milan, Italy, over a 30-year period. These results are presented in conjunction with a literature review of salivary tumors with a view to providing an up-to-date overview of the clinical course, prognosis, and treatment options for this rare tumor. PROCEDURE: Fifty-two cases of epithelial salivary tumors were reviewed and the clinical-pathological information concerning tumor characteristics, therapy, and follow-up were collected. Patients' age ranged between 4 and 18 years. RESULTS: The major salivary glands were the main site of tumor occurrence (79% of cases arose in parotid glands); 37 patients had benign tumors (pleomorphic adenoma), 15 had malignant tumors (12 mucoepidermoid carcinoma, 9 low grade). All the patients were treated by surgery; local relapses after parotidectomy were 4% and 25%, in benign and malignant tumors, respectively. When tumor enucleation was performed, recurrences occurred in 50% of benign neoplasms. At the time of the report, all patients with benign tumors were alive, 35(95%) without evidence of disease; only one patient with malignant tumor died of disease. CONCLUSIONS: Epithelial salivary glands tumor in children had different characteristics compared with their adult counterpart with respect to the frequency of histotypes and site of occurrence, but their prognosis seems to be similar. Parotidectomy (total or superficial) is the best choice for achieving good cure rates in both benign and malignant tumors.

Conservative surgical approach for thyroid and lymph-node involvement in papillary thyroid carcinoma of childhood and adolescence.

BACKGROUND: Prior to 1990s, papillary thyroid carcinomas (PTCs) in childhood/adolescence underwent a standard therapeutic approach (total thyroidectomy plus elective neck dissection, followed by radioactive iodine (RAI) ablation), with an overall survival of about 100%. The aim of this study is to outline the possibility of a conservative approach (hemithyroidectomy plus selective neck dissection of clinically involved nodes, followed by TSH-suppressive therapy) in a selected group of patients. PROCEDURE: From 1968 to 2001, 42 pediatric PTC patients were treated at our institution. Absence of distant metastases and a tumor clinically limited to one lobe were both present in 28 cases that underwent a radical (20 cases) or a conservative (8 cases) surgical approach at the thyroid level. At cervical node level, 10 patients underwent a radical and 32 a conservative surgical approach. Clinicopathologic features at onset, type of therapy (radical vs. conservative), post-operative complications, and outcome till May 31, 2004 were recorded. The impact of the type of surgery on outcome was evaluated. RESULTS: Overall and progression-free survival (PFS) curves were found to be independent of the type of therapy (radical vs. conservative) in subgroups of patients matched for extent of disease at onset. Post-operative complications occurred only with radical surgical approaches. CONCLUSIONS: Childhood and adolescence PTCs show a high rate of spread but an excellent outcome independent of the type of therapy (radical vs. conservative). Taking into account the marked responsiveness to TSH-suppression and the complications after radical therapy, in selected cases, a conservative approach should be considered, reserving more aggressive therapies in case of metastases or relapse.

Papillary thyroid carcinoma of childhood and adolescence: a 30-year experience at the Istituto Nazionale Tumori in Milan.

BACKGROUND: Survival rates are reportedly excellent for papillary thyroid carcinomas (PTCs) in childhood/adolescence, despite their strong tendency to spread. The aim of this study was to verify this assumption in a single-institution series spanning a 30-year period with a very long follow-up. PROCEDURE: From 1968 to 2001, 74 cases of thyroid carcinoma were collected. The papillary histological type was confirmed in 42 cases with available slides; we recorded the sex, age at diagnosis, age of menarche, tumor side and size, TNM/pTNM classification, multicentricity, vascular invasion, type of surgery, post-operative complications, post-surgical therapies and outcome up to May 31, 2004. RESULTS: The female/male ratio was 2.2; pT4, pN1 and M1 cases were 52%, 95%, and 12% (four in lungs and one in bone), respectively. Total thyroidectomy was performed in 33 patients, hemithyroidectomy in 8, and a biopsy in 1 inoperable case. Nine patients (21%) relapsed, six in the cervical lymph nodes and three in the lungs. After a median follow-up of 189 months, all patients were alive, two of them with evidence of disease. Overall and progression-free survival curves were independent of sex, age, TNM/pTNM classification, or type of surgery. Overall survival was also independent of recurrence. CONCLUSIONS: Unlike its adult counterpart, PTC of childhood and adolescence is a cancer with a high frequency of spread, but an excellent outcome irrespective of sex, age at diagnosis, TNM/pTNM classification, type of surgery, recurrence. Since pediatric PTCs proved highly responsive to hormone manipulation, it is worth considering a different therapeutic approach from adult cases.

Which classification for ethmoid malignant tumors involving the anterior skull base?

BACKGROUND: The purpose of this study was to compare three systems of classification for malignant ethmoidal tumors in patients undergoing anterior craniofacial resection. METHODS: A radiologic locoregional evaluation of 241 patients with malignant ethmoid tumors was performed before patients underwent an anterior craniofacial resection. Disease in each case was staged according to the American Joint Committee on Cancer-Union Internationale Contre le Cancer (AJCC-UICC) 1997 classification, the AJCC-UICC 2002 classification, and the Istituto Nazionale Tumori (INT) classification. Kaplan-Meier curves and Cox models were used to investigate the prognostic value of each classification system on disease-free survival (DFS) and overall survival (OS). The classifications were compared in terms of prognostic discrimination capability, measured by use of an index of agreement between each classification and DFS or OS time. RESULTS: All three classification systems yielded statistically significant results in the Cox analysis, both for DFS and OS. In the AJCC-UICC 2002 system, minor differences were observed between T1 and T3 tumors. The INT classification showed a progressive worsening of the prognosis with increasing stage. The index of prognostic discrimination favored the INT classification over both the 1997 and 2002 AJCC-UICC classifications. CONCLUSIONS: Both the 1997 and 2002 AJCC-UICC classifications seemed to have limited prognostic value. By contrast, the INT classification satisfied one of the main goals of tumor staging, demonstrating the progressive worsening of prognosis with different tumor classes.

A novel intraarterial chemotherapy using paclitaxel in albumin nanoparticles to treat advanced squamous cell carcinoma of the tongue: preliminary findings.

OBJECTIVE: The purpose of our study was to evaluate the effectiveness of intraarterial infusion of paclitaxel incorporated into human albumin nanoparticles for use as induction chemotherapy before definitive treatment of advanced squamous cell carcinoma of the tongue. SUBJECTS AND METHODS: Twenty-three previously untreated patients (age range, 27-75 years) who had carcinoma of the tongue (stage T3-T4, any N) received intraarterial therapy with paclitaxel incorporated into albumin nanoparticles delivered by transfemoral catheterization into the external carotid artery (10 patients), selectively into the lingual artery (12 patients), or into a faciolingual trunk (1 patient). Each patient received two to four infusions, with a 3-week interval between infusions. The dose administered was 230 mg/m(2) in eight patients, 180 mg/m(2) in six patients, and 150 mg/m(2) in nine patients. Sixteen patients underwent surgery. Of these 16 patients, eight subsequently received radiotherapy, and three received a combination of chemotherapy and radiotherapy. Of the remaining seven patients, one received chemotherapy alone, four received radiotherapy alone, one received chemotherapy plus radiotherapy, and one refused any further treatment. RESULTS: Sixty-seven infusions were performed successfully. Eighteen patients (78%) had a clinical and radiologic objective response (complete, 26%; partial, 52%). Three patients (13%) showed stable disease, and two (9%) showed disease progression. The four patients with complete clinical response who underwent surgery showed microscopic residual carcinoma measuring less than 1 mm in two patients, less than 5 mm in one patient, and less than 1 cm in one patient. The toxicities encountered were hematologic (grade 3) in two patients (8.6%) and neurologic (grade 4) in two patients (reversible paralysis of the facial nerve, 8.6%). Two catheter-related complications occurred: one reversible brachiofacial paralysis and one asymptomatic occlusion of the external carotid artery. CONCLUSION: Intraarterial infusion of paclitaxel in albumin nanoparticles proved reproducible and effective and deserves further investigation as induction chemotherapy before definitive treatment of advanced tumors of the tongue, with a view to organ preservation.