Cancer of the tongue is most common in those older than 40 years. However it can present in any adult age group and we regularly see patients in their 30’s and 40’s with this condition. We have also had a number of 20 year-olds.
It is associated with smoking and excessive alcohol intake although many of our younger patients appear to have no such risk.
Tongue cancer usually presents as a non-healing ulcer or an area of soreness that doesn’t go away. Any ulcer or area of soreness that persists beyond 3 weeks should be reviewed by a specialist in this field.
The image on the right shows a benign ulcer but this should heal within 3 weeks. If not, it must be reviewed by an expert to ensure that it is not cancer.
Occasionally there can be pain felt in the ear of the same side. This is called “referred earache (otalgia)” and is due to irritation of a tongue nerve that also supplies sensation to that ear.
Some ulcers are small at presentation but many are quite large. When large they can bleed and can be smelly. When left for a while these cancers continue to grow and can invade the jaw boneand even the overlying skin.
The image shows a large tongue cancer that is ulcerated and invading into the jaw. Often a lymph node on the same side can be involved by the cancer. This may be the first thing noticed by the patient but most are aware of the tongue problem.
- Biopsy – a non-healing ulcer or lump on the tongue should be biopsied in the clinic. This is usually done under local anaesthetic.
- CT scan – of the tongue and neck to determine the extent of tongue involvement and also whether the neck nodes are enlarged. Often the chest will also be scanned.
Treatment of tongue cancer
Tongue cancer is usually treated by surgery and in many cases post-operative radiotherapy. The extent of surgery is determined by the stage of the tumour. Stage is basically a description of the extent of the tumour and consists of 3 parts:
T stage – the size and degree of tongue involvement by the tumour
N stage – the degree of neck nodal involvement
M stage – whether there is spread to other sites such as the lungs, liver etc.
Surgery is therefore planned following the biopsy and CT scan.
Fortunately very few tongue cancers have spread beyond the neck at time of presentation although most will have involved neck nodes.
Small cancers between 1cm-2cm in diameter have a significant risk of neck nodal involvement and are usually treated by excision of a segment of tongue as well as removal of the neck nodes on that side (neck dissection).
Cancers greater than 2cm in diameter are best managed with removal of most of one side of the tongue together with a neck dissection. One can imagine that this can severely impact on speech and swallowing but with modern reconstructive techniques the functional outcome is very good. The vast majority have normal swallowing and only a slight change in speech.
When tongue cancers get over 3cm or extend deeply into the tongue the functional impact after surgery is greater but still very good articulation can be obtained.
Radiotherapy is employed after surgery where tongue cancers demonstrate overly aggressive features such as nerve or lymphatic vessel invasion. It is also employed when there is significant neck node involvement defined as more than one node involved or spread through the capsule of the node.
Radiotherapy is given for 5-6 days each week for 6 weeks. It is generally more difficult to tolerate than surgery as the effect is cumulative with the peak of the acute reaction around the end of the treatment course. The patient experiences a severe “sunburn” of the neck and mouth that usually becomes obvious 3 weeks into the treatment, reaches its peak at the completion of treatment, resolving over the next 3 weeks.
The long-term effects of radiotherapy are significant. The patient may experience a dry mouth, reduced taste, and dental problems. However, when indicated by the stage of the cancer, radiotherapy definitely reduces recurrence and maximizes the cure rate.