What is the treatment for tongue cancer?

Treatment of Tongue Cancer

For early-stage (T1-T2N0) tongue cancer, surgery alone is the preferred treatment, while locally advanced disease (T3-T4) requires surgical resection followed by postoperative chemoradiotherapy, particularly when adverse pathologic features are present. 1, 2

Initial Workup and Staging

• Complete head and neck examination with biopsy for histological confirmation is mandatory 1, 2
• Imaging should include CT or MRI with contrast of the primary site and neck 2
• PET-CT is recommended for stage III-IV disease to detect occult metastases and potentially alter management 1, 2
• Dental evaluation with panoramic imaging (Panorex) is essential for treatment planning, particularly to assess mandibular involvement 1
• Evaluate cervical lymph nodes carefully, as approximately 30% of patients present with regional node involvement, though this varies by subsite—anterior tongue cancers have 50-60% occult neck metastases 1, 2

Treatment Algorithm by Stage

Early-Stage Disease (T1-T2N0)

Surgical excision is the preferred treatment for resectable oral cavity tumors, including tongue cancer. 1, 2

• Perform glossectomy with neck dissection (ipsilateral or bilateral, guided by tumor thickness) 1, 2
• For anterior tongue cancers specifically, strongly consider bilateral neck dissection due to the high rate (50-60%) of occult metastases 1, 2
• Single-modality treatment (surgery alone) is recommended to preserve function and avoid compromising quality of life 1, 2
• If definitive radiotherapy is chosen instead (for medically inoperable patients or those refusing surgery), deliver at least 44-64 Gy to the neck for N0 disease 1

Locally Advanced Disease (T3-T4)

Primary surgical treatment followed by adjuvant therapy is the preferred approach for T3/T4 oral cavity cancers. 1, 2

• Perform surgical resection with appropriate neck dissection 1, 2
• Postoperative chemoradiotherapy (category 1 recommendation) is mandatory for: 1, 2
  • Extracapsular nodal spread
  • Positive mucosal margins (R1 or R2 resection)
• Postoperative radiotherapy with or without chemotherapy should be considered for other high-risk features: 1, 2
  • pT3 or pT4 primary tumors
  • N2 or N3 nodal disease
  • Nodal disease in levels IV or V
  • Perineural invasion
  • Vascular tumor embolism

Adjuvant Therapy Specifications

When chemoradiotherapy is indicated, use cisplatin 100 mg/m² on days 1,22, and 43 concurrent with radiotherapy (70 Gy). 1

• Deliver postoperative radiotherapy to regions with microscopically positive margins or extracapsular extension at 2 Gy/fraction to 60-66 Gy 1
• For tumor bed and involved lymph node regions without these adverse features, deliver 56-60 Gy 1
• Critical timing: Start adjuvant therapy within 6-7 weeks of surgery—delays beyond this compromise outcomes significantly 1, 2

Surgical Margins and Prognosis

• Clear surgical margins are crucial and significantly improve disease-specific survival 3
• If margins are positive and technically feasible, re-excision is preferred over proceeding directly to chemoradiotherapy 1
• Local-regional recurrence occurs in approximately 26% of patients, with salvage rates around 10.5% 4
• Most recurrences (89%) occur within the first 60 months, with 78% in the first 2 years 3, 5

Multidisciplinary Considerations

Multidisciplinary team involvement is essential due to the critical impact on mastication, deglutition, and speech. 1, 2

• Advances in microvascular reconstruction techniques have significantly improved functional outcomes after primary surgery 1, 2
• Nutrition, speech, and swallowing evaluation should be integrated into the treatment plan 2
• Patients should be counseled to stop smoking and limit alcohol consumption, as these decrease treatment efficacy 1

Critical Pitfalls to Avoid

• Never delay adjuvant therapy beyond 6 weeks post-surgery—this is the most important modifiable factor affecting outcomes 1, 2
• Do not combine surgery with radiotherapy for early-stage disease—single-modality treatment preserves function without compromising survival 1, 2
• Do not underestimate occult neck metastases in anterior tongue cancers—the 50-60% rate mandates aggressive neck management 1, 2
• Do not perform inadequate neck dissection—bilateral dissection is often necessary for anterior tongue primaries 1, 2

Surveillance

• Monitor closely for at least 5 years due to high rates of locoregional recurrence and second primary cancers (21% incidence) 3
• For patients receiving neck irradiation, check thyroid function (TSH) every 6-12 months, as 20-25% develop hypothyroidism 1