Tongue Cancer

What is Tongue Cancer?

Tongue cancer is a condition where there is an abnormal growth that develops on the tongue or at its base. This condition is grouped as Oral cancer or Oropharyngeal cancer. The tongue is the most common site for cancer. There are a few types of malignancy of the tongue but the commonest tongue cancer is squamous cell carcinoma. Squamous cells are the flat and thin cells that line the nose, mouth larynx and throat.

There are also 2 parts of the tongue, the oral tongue which is the two third front part of the tongue and the base of tongue, which the posterior one third of the tongue that extends to the throat. Tongue cancer can affect any parts of the tongue.

It is generally higher incidence in men than women, usually affecting the elderly people of more than 60 years old. There is a higher incidence in Southeast Asia, India, Pakistan and Taiwan compared to Europe and United States. It is highly associated with Betel nut chewing and tobacco smoking. Betel nut chewing is a very common practice in India and Southeast Asia.

It is very challenging to diagnose a tongue cancer as there are various lesions of the mouth, gum and throat. Most of the lesions are benign and self-limiting. The wide variety of symptoms made it even harder to diagnose or be suspicious of tongue cancer.

 

Tongue Cancer

 

  • Risk factors of Tongue Cancer
  • Symptoms of Tongue Cancer
  • Diagnosis and Investigation Tongue Cancer
  • Staging of Tongue Cancer
  • Treatment of Tongue Cancer
  • Conclusion

 

Risk Factors of Tongue Cancer

Not every patient with tongue cancer has a risk factor. Some patients have one or multiple risk factors and some just don’t have any risk factors.

Some of the identified risk factors are older age group of more than 60 years old, men, smoking, alcohol intake and betel nut chewing. It is also more common in Asian and African American compared to Caucasians.

One important risk factor is Human papillomavirus (HPV), HPV18 and HPV16. This is the strongest risk factor for tongue cancer as HPV DNA has been isolated from up to 50% of tongue cancer cases.

A common but very invasive lesion is the precancerous lesion of the mouth called oral leukoplakia. It appears as a white plaque or patch in the oral mucosa. This lesion represents the hyperplasia of squamous epithelium that lines the oral mucosa. It is the early stage or malignancy that starts with hyperplasia, proceed to dysplasia, carcinoma in situ and finally a malignancy. With that, leukoplakia can also be a benign lesion with just inflammatory cells, which is associated with HPV. Between 1-20% of leukoplakia will advance further to a malignancy in 10 years. It is always advisable to have these lesions biopsied to rule out malignancy.

A separate disorder, which is not premalignant, is oral hairy leukoplakia, an Epstein-Barr virus-induced lesion that occurs almost entirely in HIV-infected patients.

 

Symptoms of Tongue cancer

Similarly to most cancer of other parts of the body, the symptoms can be vague, benign or even symptomatic until metastasis stage. Most will have just a couple of vague symptoms which is not deemed important until late stage.

One of the common symptoms that may be present is patches on tongue that could be white or red in colour. The consistency of the patch is usually firm or hard and the edges are irregular. Most of the patches start small and are not noticed or dismissed, until the patches are big or causing pain. Theses patches can also bleed when pressure is exerted such as during swallowing or mouth rinsing. The bleedings are usually in small amount and will stop after a few minutes, which is myth not many patients are too bothered by this symptom.

There can also be a growth that is felt on the tongue. It may be small or large on detection. Most of the tumour on oral tongue is at the lateral or lower surface of the tongue. The tumour can sometimes invade the musculature of tongue or the floor of mouth.  Cancer of base of tongue can invade the musculature of tongue, floor of mouth, the tonsils and its surrounding.

Occasionally the patients will have slow healing ulcer on the throat. This can present as frequently of every month to every few months. These ulcers can take weeks to heal, differentiating it from the common ulcers that usually heal within few days.

Another common symptom is pain during eating or chewing. This may start with little pain and slower increases in due time of the course of illness. However, not every patient experiences this symptom. A prolonged and frequent sore throat is also part of vague symptom of the tongue cancer.Together with that, hoarseness of voice or a change in voice points toward a malignancy or oral cavity. There can also be numbness around the mouth or in the lower parts of face, at the jaw line.

Sometimes, patient may feel that his/her tongue is stiff or enlarge causing an effect on their speech. When the tongue is stiff, it is difficult to articulate some word and may cause the speech to sound as mumbling. The change in speech is usually noticed by family members or work colleagues.

Symptoms suggestive of malignant cancer are unexplained progressive loss of appetite and loss of weight. Patients will also feel lethargic at most time. The lymph nodes could be enlarged at the neck region, just like when one is down with glandular fever.

 

Diagnosis and Investigation of Tongue Cancer

It will usually start with a general physical examination and an examination of the oral cavity. A direct visualization of the oral cavity including the throat until the vocal cords is vital. This can be done with a flexible laryngoscope. From this, any tumour or lesion on the tongue, buccal mucosa, floor of mouth or base of tongue can be visualized. From the appearance of it, a clinician or physician can estimate whether it is of benign or malignant tumour. Nevertheless, they have to be further investigated.

It is important to get a biopsy of the oral lesion or a non-healing ulcer. With the biopsied piece under microscope, histopathological examination can be done for a diagnosis.

 

Ultrasound

This examination is done using the probe and a sound wave. It is used mainly for the assessment of cervical lymph nodes and evaluation of primary tumour if possible. The characteristic of the enlarged lymph nodes could suggest of a benign or malignant origin if evaluated by an experienced sonographer.

 

Computered Tomography Scan (CT Scan)

It is a quick investigation and widely available. This is an important investigation when tongue cancer is suspected.

The CT scan is the most commonly used for the assessment of tongue cancer for staging of the tumour and also nodes metastasis. The exact size, thickness and location of the tumour are seen.The extension of the tumour can also be seen on the film, to see if it is beyond the midline or the musculature of tongue. The adjacent structures can be seen on the film of a CT Scan such as the lymph nodes, floor of mouth, mandible and others to look for local metastasis and invasion.

The tumour or tongue lesion will have a different appearance from the normal tongue. It will look more attenuated than normal musculature of tongue as the tumour is mostly made of squamous cell. It will also enhance if a contrast is given.

 

Magnetic Resonance Imaging (MRI)

Magnetic Resonance Imaging (MRI) is done when tongue cancer is highly suspicious to look at the exact location and size of mass and for lymph nodes enlargement. This investigation is also crucial to look for distant metastasize to other structures of the body. MRI is the preferred investigation method in the evaluation of tongue carcinomas.

MRI provides valuable information for structures both within and beyond the tongue. The tongue carcinoma may extend and infiltrate much far beyond the gross tumour margin that seen on surgery by naked eye. This is often the difficulty faced by the surgeon as he needs to see the margins during the resection. The spread of tongue cancer to other structures in the head and neck region can also be seen.

 

Staging of Tongue Cancer

It is crucial to have an accurate staging of tumour because the course of treatment depends on that. Staging helps the physician in planning the treatment course, to provide a prognosis to the patient, to evaluation the outcome of given treatment and also to facilitate researches in research and study for better treatment.

Currently, the Tumour Node Metastasis (TNM) classification is used for most of the malignancy staging. The TNM staging includes the tumour size, regional involvement and if it includes and distant metastasis.

T is the characteristic of Primary tumour
TX Primary tumour cannot be assessed clinically
T0 No evidence of presence of primary tumour
Tis Carcinoma in situ
T1 Tumour of 2 cm or lesser
T2 Tumour larger than 2 cm but less than 4 cm in greatest dimension
T3 Tumour larger than 4 cm in
T4a (oral tongue) Tumour that invades cortical bone, into deep or extrinsic muscle of tongue (genioglossus, hyoglossus, palatoglossus, and styloglossus), the maxillary sinus, or skin of the face
T4b (oral tongue) Tumour that invades the masticator space, pterygoid, or base of skull, or encases internal carotid artery
T4a (pharyngeal tongue) Tumour that invades any of the following: larynx, deep/extrinsic muscle of tongue (genioglossus, hyoglossus, palatoglossus, and styloglossus), medial pterygoid muscle, hard palate, and the mandible
T4b (pharyngeal tongue) Tumour that invades any of the following: lateral pterygoid muscle, pterygoid plates, lateral nasopharynx, base of skull; or encases the carotid artery
N is for Regional lymph nodes
NX Regional lymph nodes cannot be assessed by any investigations
N0 No regional lymph node metastasis
N1 Metastasis to a single ipsilateral lymph node, 3 cm or lesser
N2 Metastasis to a single ipsilateral lymph node, larger than 3 cm but lesser than 6 cm; or to multiple ipsilateral lymph nodes larger than 6 cm; or to bilateral or contralateral lymph nodes, lesser than 6 cm in greatest dimension
N2a Metastasis to a single ipsilateral lymph node, larger than 3 cm but lesser than 6 cm in greatest dimension
N2b Metastasis to multiple ipsilateral lymph nodes larger than 6 cm
N2c Metastasis to bilateral or contralateral lymph nodes, lesser than 6 cm in greatest dimension
N3 Metastasis to lymph nodes that is larger than 6 cm
M—Distant metastasis
MX Distant metastasis cannot be assessed
M0 No distant metastasis
M1 Distant metastasis present

 

Stage grouping

Stage 0 Tis N0 M0
Stage I T1 N0 M0
Stage II T2 N0 M0
Stage III T1, T2 NI M0
T3 N0, N1 M0
Stage IVA T1, T2, T3 N2 M0
T4a N0, N1, N2 M0
Stage IVB Any T N3 M0
T4b Any N M0
Stage IVC Any T Any N M

Video of Tongue Cancer

At presentation, up to 35% patients have metastasis to the lymph nodes and of those,5% have involvement of bilateral lymph nodes. The tongue has a rich lymphatic network with efficient lymph drainage. The lymph drains to the nodes of the same side, called ipsilateral and to the nodes of the opposite side, called contralateral. The nature of draining to both sides of lymph nodes is called bilateral. Lymphatic from the margins of outer oral tongue drains to the ipsilateral submandibular and jugulodigastric nodes while the lymphatic from tip of the tongue drains to submental lymph nodes. The central of the tongue drains to bilateral cervical lymph nodes.

 

Treatment of Tongue Cancer

It is uncommon to have a single therapy for tongue cancer as it is not effective enough for a cure or to prevent recurrence. Most of the time, chemotherapy and radiotherapy are administered before the surgery to shrink the size of tumour. Sometimes, after a surgery of small tumour, chemotherapy or radiotherapy is administered to kill the remaining cancer cells, or to prevent a recurrence.

As the tongue is an important structure for speech and eating, it is important to have a good rehabilitation to preserve as much function as possible of the tongue. After a surgery, whether it is just an excision of small tumour or removal of the whole tongue, called glossectomy, the function of the tongue will be impaired at various degrees. For that, the rehab therapist has to be aware as well as the patient to achieve better quality of life.

 

Chemotherapy

Chemotherapy is a treatment line where chemotherapeutic agents that are used to kill the malignant cells so that they stop proliferating or growing. This is a common treatment before therapy to shrink the size of tumor so that the excised tumor is smaller. Chemotherapy is not the definitive treatment for tongue cancer and is usually not used as a single therapy. Most of the time, chemotherapy is combined with radiotherapy or surgery for a better outcome.

Chemotherapy is also used after surgery to prevent recurrent malignancy. There is also a regime called palliative chemotherapy where the disease is in very advance or late stage. With chemotherapy, more comfort can be provided for the patient, together with endof life care.

There are many side effects from chemotherapy as it kills all rapid proliferating cells. With that, the bone marrow, digestive tract and hair follicles are often affected too as they are rapidly proliferating cells. The common side effects that we often see is myelosuppression where there could low counts of white blood, haemoglobin and platelets. The digestive tracts are often affected with mucositis that is painful and cause even more difficulty in swallowing.

The common chemotherapy drugs that can be used to treat tongue cancer or other head and neck cancers are Cisplastin and Fluorouracil. The less common ones are Carboplastin, Bleomycin and Methotrexate. The selection of chemotherapeutic agents depends on the preference of the physician and also the availability in that particular health centre.

 

Radiotherapy

Radiotherapy is a radiation treatment that involves electron beams, high-energy X-rays or radioactive isotopes to kill the cancerous cells. This therapy can be used before or after surgery. It can also be used with chemotherapy, called chemoradiotherapy which is a more effective treatment.

A new therapy called the IMRT is a precisely calculated dose of radiation by a computer for the tumour. With this, the radiation exposure to surrounding non cancerous, normal structures will be minimizing to reduce the side effects. This is more effective and have less side effective than the conventional radiotherapy that is commonly used.

 

Surgery

For a small tumour in tongue cancer, it is best to remove the tumour surgically and then followed by chemotherapy or radiotherapy. For a large tumour, an adjuvant chemoradiotherapy is given before the surgery to shrink the tumour first before removal of tumour or removal of the whole tongue, glossectomy. Sometime, chemotherapy or radiotherapy is needed after surgery to kill any possible cancer cells that are not removed.

There are two ways to approach the tongue. Either by transmandibular approach which need a removal of many structure or by transpharyngeal approach. The latter has smaller incision, with fewer traumas to the surrounding structures and also has less complication of aspiration. However, the tumour free margins and survival rate remains the same for these 2 approaches.

A neck or lymph nodes dissection is also done during the surgery to identify the lymph nodes of the neck and remove it. Most malignancy will spread to the lymph nodes and the removal of lymph nodes act as a precaution and also treatment. Head and neck malignancies have a high incidence of occult metastasis.

The surgeries are also very high risk as there are many important structures in the head and neck region. Sometimes, a reconstruction surgery is done too when a big structure or tissue is taken out. The reconstruction is important to preserve the outward appearance of the patient so that he will not be socially withdrawn or home bound.

 

Rehabilitation

After surgery or chemoradiotherapy, many patients will have problems with speech, eating and swallowing. So, it is important for rehabilitative therapy by speech therapist and physiotherapist. This is to help regain the speech and eating ability to restore the functions as normal as possible and to provide a good quality of life.

Many patients will be depressive and socially withdrawn during or after the therapies. It is important to help them adapt socially and to watch out for symptoms of depression. Family support and encouragement is the best remedy and help for them.

 

Conclusion

The symptoms of tongue cancer are very vague and not definitive. That makes it very difficult for physicians to diagnose tongue cancer compared to other cancers.  So, it is very important that people with risk factors and the symptoms to seek early consultation for early detection of tongue cancer. If it is detected early before metastasis, the survival rate is very high with good quality of life. It is also important for physicians, both in medical and dentistry to pick up these symptoms and be suspicious of tongue cancer. Early detection with early diagnosis and prompt treatment is crucial.

 

 

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