What is the treatment for tongue cancer?

Treatment of Tongue Cancer

Surgery is the primary treatment for tongue cancer, with surgical excision recommended for T1-T2 tumors and surgery followed by adjuvant therapy for T3-T4 disease. 1

Initial Evaluation

Before treatment, perform these essential assessments:

• Biopsy for histological confirmation of squamous cell carcinoma 1
• Cervical lymph node evaluation, as approximately 30% of patients present with regional node involvement 1
• CT with contrast and/or MRI of the primary tumor and neck 1
• PET-CT for stage III-IV disease to assess for distant metastases 1
• Baseline voice and swallowing function assessment to guide treatment selection and measure post-treatment outcomes 1
• Dental/prosthodontic evaluation with jaw imaging as indicated 1

Treatment Algorithm by Stage

Early Stage (T1-T2) Disease

Single-modality surgical treatment is recommended to avoid compromising functional outcomes 1, 2:

• Surgical excision of the primary tumor with neck dissection 1
• For anterior tongue cancers, perform bilateral neck dissection due to the 50-60% rate of occult neck metastases 1
• For lateral tongue lesions, ipsilateral neck dissection is typically sufficient unless midline involvement is present 1
• Minimally invasive approaches are preferred when feasible 2

Critical pitfall to avoid: Do not combine surgery with radiotherapy for early-stage disease, as this compromises functional outcomes without survival benefit 1, 2

Advanced Stage (T3-T4) Disease

Surgery followed by adjuvant therapy is the standard approach 1, 3:

• Perform glossectomy (partial, hemi-, or subtotal depending on tumor extent) 3
• Bilateral neck dissection is recommended, preserving the sternocleidomastoid muscle, jugular vein, and spinal accessory nerve when feasible 3
• For T4 tumors, surgical treatment is associated with significantly better survival compared to non-surgical approaches 2, 3

Adjuvant Therapy Guidelines

High-Risk Features Requiring Chemoradiotherapy

Postoperative chemoradiotherapy (Category 1 preferred) is mandatory for 1, 3:

• Extracapsular nodal spread
• Positive mucosal margins

Regimen: Concurrent single-agent cisplatin at 100 mg/m² every 3 weeks 1, 3

Intermediate-Risk Features

Consider postoperative radiotherapy with or without chemotherapy for 1:

• pT3/pT4 primary tumors
• N2/N3 nodal disease
• Nodal disease in levels IV/V
• Perineural invasion
• Vascular tumor embolism

Radiation Delivery

• Deliver radiotherapy to the tumor bed and involved lymph node regions 2
• Escalate dose if microscopically positive margins or extracapsular extension present 2, 3
• Critical timing requirement: Start adjuvant therapy within 6 weeks post-surgery, as delays beyond this timeframe negatively impact outcomes 1, 2, 3

Multidisciplinary Team Requirements

All treatment decisions require multidisciplinary team evaluation including 1:

• Surgical oncology
• Medical oncology
• Radiation oncology
• Speech pathology
• Nutrition/dietetics
• Dental/prosthodontics
• Psychology and rehabilitative services

Integrate nutrition, speech, and swallowing evaluation/therapy throughout the treatment course 1, 3

Functional Outcomes

Advances in microvascular reconstruction techniques have significantly improved functional outcomes after primary surgical management 1, 3

For base of tongue tumors specifically:

• T1-T3 disease: Surgery with or without radiotherapy provides similar local control rates 2
• T4 base of tongue: Combination surgery and radiotherapy may offer advantage, though outcomes remain poor 2, 3

Key Pitfalls to Avoid

• Never delay adjuvant therapy beyond 6 weeks post-surgery - this significantly worsens outcomes 1, 2, 3
• Do not underestimate occult neck metastases risk - anterior tongue cancers have 50-60% occult metastases rate requiring bilateral neck dissection 1
• Avoid combining surgery with radiotherapy for T1-T2 disease - single-modality treatment preserves function without compromising survival 1, 2
• Do not attempt organ preservation in patients with nonfunctional larynx or extensive T4a disease - primary surgery (usually total laryngectomy) is recommended 4