Tongue Cancer

What is Tongue Cancer?

Oral cavity cancer, not including skin cancer, is the most frequent type of head and neck cancer. 90% of these cancers are squamous cell carcinoma (a type of skin cancer), with the remaining being minor salivary gland cancers and other rare tumors. The tongue, along with the lip and the base of the mouth, is most often affected.

Interestingly, while the front two-thirds of the tongue are considered part of the oral cavity, the back third (base of the tongue) is considered part of the throat. Even though both have similar cell structures, a cancer at the base of the tongue is treated differently and has different implications in terms of treatment, life expectancy, and follow-up.

Despite improvements in detecting and treating oral cancer lately, the long-term survival rates for advanced-stage tongue squamous cell carcinoma is still low, with only about 50% of patients living beyond 5 years.

Pictures of the body (imaging) are needed to help doctors accurately determine the extent and location of the disease, and to see how the tumor interacts with the surrounding areas. They also check the lymph nodes in the neck, as cancer commonly spreads here from the oral cavity. Treatment is tailored to each patient’s needs and generally involves surgery, with a combination of chemotherapy and radiation therapy used in some cases. The goal of treatment is to completely cure the disease while keeping or restoring as much normal function as possible. It’s important to keep up with follow-up appointments, as it’s not uncommon for the cancer to return in the same or nearby areas, and such recurrence should be treated immediately.

What Causes Tongue Cancer?

The main factors that increase the chances of developing tongue cancer are heavy smoking and drinking a lot of alcohol. Cigarette smoke has substances that can cause cancer, like nitrosamines and polycyclic hydrocarbons. Alcohol turns into a chemical called acetaldehyde, which can affect the way our body repairs our DNA.

Lesser-known factors can also play a role, like chewing betel nuts, being exposed to radiation, having a weakened immune system, poor mouth cleanliness, and genetics. Having a Human papillomavirus (HPV) infection can contribute too. In fact, recent research suggests that people with HPV-related cancer at the base of the tongue can have a better response to treatment, and are more likely to survive, compared to those whose cancer isn’t linked to HPV.

HPV-positive tumors in the base of the tongue and throat seem to respond really well to chemotherapy and radiation therapy. So much so, experts are looking into reducing the intensity of treatment in the hopes of minimizing side effects, yet still achieving successful treatment outcomes.

This positive correlation has also been studied in other parts of the head and neck, like the mouth. However, up to now, no strong associations have been found. So, it seems that having an HPV infection doesn’t have any effect on the treatment plan or the outcome for cancers in the front two-thirds part of the tongue. It’s important to note that the role of HPV in head and neck cancers is still quite new, and there’s a lot of ongoing research in this area.

Additionally, another interesting study done in 1953 found that even though the cells around a mouth cancer tumor appeared to be healthy, upon closer examination, these cells showed signs of pre-cancer or cancer changes. This reinforced the idea that oral cancers can start in multiple places instead of just one abnormal cell. Though this concept is still not fully understood, it’s crucial to understanding why tongue cancer can be so aggressive and prone to coming back.

Risk Factors and Frequency for Tongue Cancer

Tongue cancer is often seen in older males who have a history of smoking and/or drinking alcohol. It is slightly more common in men, and its occurrence can vary significantly based on geographic location. In the past, the rate of tongue cancer has been declining, potentially due to the global decrease in smoking.

However, research points out that there has been an alarming increase in the rates of oral and tongue base cancer in recent years, specifically among women and younger patients who don’t possess the traditional risk factors such as alcohol or tobacco use. This surge is partly due to an increase in tongue cancer linked to the Human Papillomavirus (HPV). There are also ongoing investigations into additional genetic factors that might explain why the disease is affecting different demographics.

Signs and Symptoms of Tongue Cancer

When evaluating patients for possible oral cavity carcinoma, doctors usually begin with a detailed medical history, particularly focusing on the head and neck region. The characteristic patient is often an elderly male who has a history of smoking or alcohol consumption, and often reports an unresolved lesion in the mouth or tongue. Other common symptoms include a sharp pain in one area, difficulty swallowing, weight loss, speech difficulty, painful swallowing, or changes in diet. A sudden observation of neck lumps or nodules can also indicate that the disease has spread locally. Other worrisome signs such as blocked nose on one side, hearing loss in one ear, or earache on one side can suggest that the disease might have extended beyond the mouth to the throat.

During the physical examination, the doctor will pay close attention to the head and neck areas. They will check the neck for swollen lymph nodes, especially under the chin, and the regions along the jaw and neck. A detailed examination of the mouth is done to closely inspect the lesion or tumor, noting its location, look, color, size, edges, and whether it is ulcerated or not. Palpating, or feeling the tongue and base of it is also important to determine the areas affected by the tumor. This examination can highlight hard or protruding parts that are not symmetrical.

Certain symptoms might hint at how far the tumor has spread. For instance, if the tumor affects the hypoglossal nerve or tongue muscle, the tongue may move towards one side. If the lingual nerve is involved, there could be changes in tongue sensation. Involvement of the inferior alveolar nerve could lead to numbness in the chin, lower lip, and/or lower teeth, suggesting that the disease is more advanced. In these cases, doctors also recommend looking at the patient’s upper airway, as risk factors for oral cavity cancer are also common for other head and neck sites. An examination involving a flexible tube inserted through the nose under local anesthesia can help rule out suspicious changes in the nose, nasopharynx, throat, larynx and voice box.

Testing for Tongue Cancer

If your doctor suspects that you might have a disease affecting your tongue, there are a few different exams and tests they might use to investigate further. Examining your tongue in a clinical setting is usually pretty straightforward, and if there are any unusual areas (or lesions), these can be tested. The methods for this might include a procedure called an incisional biopsy or a punch biopsy. These are simple procedures carried out under local anaesthesia where a small sample of the lesion is taken for further investigation.

If the suspected area is at the base of the tongue and hard to see or reach, your doctor might use a method called flexible laryngoscopy for a better look or to take a sample. This might need to be done under general anesthesia. If there are noticeable lumps in your neck (which could be enlarged lymph nodes), your doctor might also use an ultrasound-guided fine-needle aspiration (FNA) biopsy. This is where a small sample is taken from the lump using a thin needle, guided by an ultrasound scan.

A type of scan called a Computed Tomography (CT) scan, which uses X-rays to create detailed images of the inside of your body, may also be carried out. This scan will help the doctor understand the size, exact location and other details of the tumor. They might also look at the lymph nodes in your neck to see if they appear unusual. If the doctor thinks your disease may be advanced, they might also scan your chest or even your whole body using either another CT scan or a scan called a positron emission tomography (PET)/CT. This is to check for signs that the disease has spread elsewhere in your body, a process known as metastasis.

Treatment Options for Tongue Cancer

Treatment for tongue cancer usually involves surgery, though radiation therapy also plays an important role, especially in cases of advanced disease, complications during surgery, or when the tumor cannot be removed by surgery. If it’s possible, the primary treatment method for squamous cell carcinoma of the tongue is surgery. The ultimate aim of any treatment is to completely cure the disease while minimizing side effects and preserving the person’s ability to function.

In general, tongue cancer that’s in the early stages (known as T1 or T2) can be successfully treated with just one type of therapy, either surgery or radiation. But when taking into consideration long-term side effects of treatment and other factors, surgery is often the recommended first step.

For patients with more advanced cases of the disease (known as T3 or T4), treatment using single-mode methods tends not to work as well. In these cases, research has found that a combination of surgery and chemotherapy along with radiation therapy (known as chemoradiation) after surgery can offer better outcomes. It’s important to note that chemoradiation used as the first step often doesn’t control the disease as well as other methods, can affect a patient’s prognosis negatively, and often leads to more complex surgery.

Different surgical treatments are used depending on the size of the tumor. These can range from removing a small portion of the tumor with some healthy tissue around it (known as a wide local excision and primary closure) for smaller tumors, to removing a larger area that includes parts of the tongue, mouth floor, or the jawbone for more advanced tumors. Depending on the extent of the surgery, reconstruction may be needed using skin or muscle from another part of the body (known as flaps or free flaps). Reconstruction can help to optimize function for swallowing and speaking after surgery. When compared to free flaps, alternatives have the benefits of shorter operation times, less complication at the donor site, and good reliability.

For a type of tongue cancer linked to the human papillomavirus (known as HPV-related squamous cell carcinoma), the treatment strategy has changed greatly in the past few decades. Trans-oral robotic surgery is used mainly for early stages, whereas advanced stages are usually treated with primary radiation and chemotherapy due to its excellent response. This treatment strategy is supported by research and is different from strategies used for HPV-negative tongue cancers.

It’s important to also manage the neck area when treating tongue cancer since re-occurrence or persistence of the disease in the neck after treatment often leads to a poor prognosis. Because of a high risk of the disease spreading to lymph nodes in the neck, many surgeons would agree that in many cases, a surgical procedure to remove lymph nodes in the neck (known as neck dissection) should be considered. If there’s evidence of the disease in the lymph nodes, a combination of chemotherapy and radiation therapy is usually needed after surgery.

In recent times, a type of therapy that helps strengthen one’s immune system (known as immunotherapy) is being used more frequently, either in combination with chemotherapy or by itself. There’s ongoing research as to whether these therapies can help in cases of squamous cell carcinoma of the head and neck.

For patients with the disease spread to distant parts of the body (known as metastasis), surgical treatment isn’t usually appropriate. In these cases, primary chemoradiation, chemotherapy, or immunotherapy are used as treatments.

What else can Tongue Cancer be?

These are various medical conditions, typically related to tumors or growths, that might be diagnosed based on certain symptoms:

• Squamous cell carcinoma (a type of skin cancer)
• Leukoplakia (white patches in the mouth)
• Carcinoma in situ (early stage cancer)
• Sarcoma (a type of cancer that starts in bones or soft tissues)
• Rhabdomyosarcoma (a rare cancer that begins in the muscles)
• Lymphoma (cancer of the lymph nodes)
• Rhabdomyoma (usually benign muscle tumor)
• Neurofibroma (typically benign nerve tumor)
• Pyogenic granuloma (non-cancerous skin growth)
• Papilloma (common types of warts)
• Vascular or lymphatic malformation (abnormal clusters of blood or lymph vessels)
• Lingual thyroid (a condition where an overactive thyroid gland enlarges and protrudes into the mouth)
• Dermoid cyst (benign growth often present at birth)
• Epidermoid cyst (a small, slow-growing, benign cyst usually found on the skin)

What to expect with Tongue Cancer

A recent study examined the occurrence and survival rates of a type of mouth and throat cancer, known as oral tongue squamous cell carcinoma. The study reported that although the number of new cases is increasing for both this type of cancer and a related one called oropharyngeal squamous cell carcinoma, survival rates have also significantly improved.

The research found that from 1976 to 2015, these two types of cancer each showed the highest absolute increase in survival rates. Regardless of the treatment used, over 90% of patients with both diseases survived—a remarkable improvement.

Possible Complications When Diagnosed with Tongue Cancer

: The potential problems that can arise after surgery include bleeding, infection, and the formation of a passage between the mouth and skin, known as an orocutaneous fistula. When a surgical method called a free or pedicled flap is used, complications could include infection, bleeding at the source of the flap, or partial or complete loss of the flap due to infection. The extent of the surgery and the success of the reconstruction can also cause problems related to function, such as difficulties with speaking, swallowing, and pain while swallowing.

Sometimes a surgical opening into the stomach, or a gastrostomy, is needed during surgery if it is thought that restoration of speech and swallowing will be difficult or take a considerable time. If significant swelling of the oral cavity and throat is expected after surgery, creating a temporary breathing hole in the neck, or tracheostomy, is common.

Complications from radiation therapy can arise and include sores in the mouth and throat, skin injury, skin infection, changes in taste, dry mouth, scars, and numbness in the mouth. One of the most challenging complications from radiation in the mouth/throat area is a condition where the jawbone dies due to radiation, known as mandibular osteoradionecrosis, which may require surgical intervention ranging from simple cleaning of the dead bone to removal and reconstruction of that part of the jawbone.

There has been debate over the use of treatments such as hyperbaric oxygen therapy as while it has been used as a treatment for jawbone death due to radiation. Some surgeons suggest it may increase the chances of the cancer returning, or may stimulate the growth of remaining undesired micro-organisms. No definitive scientific studies have been able to prove this correlation, and the choice to use it is left to the individual clinician.

Side effects that may occur in the neck region post-radiation include scars, stiff neck, numbness, and the slowing or stoppage of the thyroid gland among others. One can also develop a condition known as esophageal stenosis, which is the narrowing of the food pipe due to scarring post-radiation. This can develop even years post-therapy.

One of the most feared complications of advanced-stage head and neck cancer is an explosive rupture of a large artery in the neck, known as carotid blowout. This usually causes severe bleeding and was once considered regularly fatal. These days, however, the mortality rate is near 60% due to advancements in surgical and non-surgical interventions. Still, this has high risks attached, and the chance of severe issues such as re-bleeding and stroke is high.

Recovery from Tongue Cancer

Small tumors often need only minor reconstruction, with the person’s ability to use their mouth normally, largely preserved. However, with bigger or more advanced diseases, rebuilding and regaining lost functions can be much harder. The goal is not just to restore appearance, but also improve the ability to use teeth and jaw, chew food, speak clearly, and swallow.

In severe cases, where reconstruction includes removal of part of the jaw, traditionally, removable prosthetics were used to restore the ability to use teeth and chew. However, these often brought less than satisfactory results. Nowadays, dental implants are more commonly used for people who have had a part of their jaw restored with surgical tissue replacement (also known as free flap mandibular reconstruction).

To achieve the best outcomes for people recovering from oral cancer, it’s crucial that speech therapists, dental experts, and cancer surgeons work together effectively and communicate well.

Preventing Tongue Cancer

Before going through a surgery on the mouth and any related reconstructive work, it’s crucial for the patient and their family to know what to expect. You should know that the surgery is just the first step in a lengthy journey of rehabilitation and follow-up care.

If you smoke or drink alcohol, it’s highly recommended that you quit. Continuing these habits during your treatment could increase the chance of your health issues returning. Therefore, getting help to quit smoking or drinking is important. Your doctor can provide you with medical options to help you stop. If they can’t, they’ll make sure to recommend you to another doctor who can.