Initial Treatment for Squamous Cell Carcinoma of the Tongue
For squamous cell carcinoma of the oral tongue, primary surgical resection is the preferred initial treatment, followed by adjuvant radiotherapy or chemoradiotherapy based on pathological findings. 1, 2
Treatment Algorithm by Disease Stage
Early Stage Disease (T1-T2)
Single-modality treatment should be pursued whenever possible for early disease. 1, 2
Surgery is the preferred approach for T1-T2 oral tongue cancers, with excellent disease-specific survival rates of 77-84% at 5 years. 2, 3
Conservative surgical options include transoral laser microsurgery or transoral robotic surgery for appropriately selected cases. 2
Radiotherapy (external beam or brachytherapy) represents an alternative for stage I disease when surgery is contraindicated, though surgery remains preferred based on functional outcomes. 2, 4
Locally Advanced Disease (T3-T4)
Primary surgical treatment followed by adjuvant therapy is the preferred treatment for T3/T4 oral cavity cancers. 1, 2
Standard options include either surgery plus adjuvant (chemo)radiotherapy or primary concurrent chemoradiotherapy, but surgery is specifically preferred for oral cavity primaries. 1
Indications for Adjuvant Therapy After Surgery
Adjuvant Radiotherapy Alone
Postoperative radiotherapy is indicated for: 1, 2
- pT3-T4 tumors
- Perineural infiltration
- Lymphatic infiltration
- More than one invaded lymph node
- Presence of extracapsular infiltration
Adjuvant Chemoradiotherapy
Postoperative chemoradiotherapy is mandatory for: 1, 2
- R1 resection (microscopically positive margins)
- Extracapsular extension (extracapsular rupture)
The standard chemotherapy regimen is cisplatin 100 mg/m² on days 1,22, and 43 concurrent with radiotherapy (70 Gy). 1, 2
Critical Timing Considerations
Postoperative radiotherapy or chemoradiotherapy must start within 6-7 weeks of surgery to optimize outcomes. 1, 2
Delays beyond this timeframe significantly compromise locoregional control and survival. 1
Technical Radiotherapy Requirements
- All patients receiving radiotherapy must be treated with intensity-modulated radiotherapy (IMRT) or volumetric modulated arc therapy (VMAT) to minimize toxicity while maintaining efficacy. 1, 2
Alternative Approaches for Cisplatin-Ineligible Patients
For patients unable to tolerate cisplatin: 1
- Carboplatin combined with 5-fluorouracil
- Cetuximab concurrent with radiotherapy
- Hyperfractionated or accelerated radiotherapy without chemotherapy
Essential Pre-Treatment Considerations
Treatment decisions must be discussed in a multidisciplinary team including surgical oncology, radiation oncology, medical oncology, and supportive care specialists (nutrition, speech/swallowing). 1, 2
Patients should be treated at high-volume facilities for improved outcomes. 1, 2
Dental examination and necessary extractions must be completed before radiotherapy. 1
Nutritional status must be optimized prior to treatment initiation. 1
Important Caveats
The choice between surgery and radiotherapy for early disease should prioritize expected functional outcomes, though surgery generally provides superior long-term function for oral tongue cancers compared to base of tongue lesions. 2, 4
Induction chemotherapy is NOT routinely recommended for oral cavity cancers and should not delay definitive surgical treatment in resectable disease. 1
Neck dissection is not recommended if FDG-PET is negative with normal-sized lymph nodes at 12 weeks post-chemoradiotherapy (for non-surgical primary treatment). 1, 2