What is the recommended surveillance schedule for a patient with stage I (T1 N0 M0) squamous cell carcinoma of the tongue after curative surgical resection without adjuvant therapy?

Surveillance Schedule for Stage I Tongue Cancer After Surgery

For stage I (T1N0M0) oral tongue squamous cell carcinoma treated with curative surgical resection alone, surveillance should include clinical examination every 3 months for the first 2 years, then every 6 months for years 3-5, followed by annual visits through at least 10 years, as local recurrence and second primary tumors can occur late and are highly salvageable when detected early. 1, 2

Surveillance Frequency and Duration

Years 1-2: Every 3 Months

• Clinical examination with careful oral cavity inspection and neck palpation is essential during this high-risk period 1
• The majority of recurrences in early-stage disease occur within the first 2-3 years, though stage I disease shows a concerning pattern of late failures 2
• Flexible laryngoscopy should be performed to evaluate for second primary tumors throughout the upper aerodigestive tract 1

Years 3-5: Every 6 Months

• Continue clinical surveillance as local recurrence can present beyond 3 years 2
• In stage I oral tongue cancer, 22.3% of patients developed late disease recurrence (>36 months), with local recurrence occurring at a mean of 48.7 months 2
• Maintain vigilance for second primary tumors, which occurred in 11.6% of stage I patients 2

Years 6-10: Annually

• Long-term follow-up through 10 years is mandatory for stage I oral tongue cancer, as 33% of deaths occurred in patients considered disease free at 36 months 2
• The effectiveness of routine follow-up remains valuable even in early-stage disease, as salvage rates for early-detected local recurrence are excellent 3, 2
• After 5 years, the frequency of new events decreases but second primary tumors continue to emerge 3

Key Components of Each Surveillance Visit

Clinical Examination

• Comprehensive oral cavity and oropharyngeal examination to detect mucosal abnormalities at the primary site 1
• Neck palpation to assess for lymphadenopathy; any suspicious nodes require tissue diagnosis 1
• Flexible laryngoscopy for visualization of the larynx and hypopharynx 1

Imaging Considerations

• Routine surveillance imaging is not recommended for asymptomatic stage I patients with negative clinical examinations 4
• Imaging (contrast-enhanced CT or MRI) should be reserved for patients with concerning symptoms or physical findings 1
• The ACR NI-RADS system provides a framework: stable postoperative changes without discrete nodules or masses are categorized as NI-RADS 1 and require only clinical follow-up 4

Red-Flag Symptoms Requiring Urgent Evaluation

Patients should be counseled to seek immediate evaluation for:

• Progressive dysphagia (suggests recurrence rather than stable radiation effects) 1
• New or enlarging neck mass 1
• Persistent or worsening pain at the primary site 1
• Voice changes or new cough (may indicate aspiration or laryngeal involvement) 1

Workup for Suspected Recurrence

• Contrast-enhanced CT or MRI of the head and neck 1
• Tissue diagnosis via biopsy of suspicious mucosal lesions or fine-needle aspiration of neck masses 1
• Consider PET/CT when imaging suggests recurrence 1

Critical Pitfalls to Avoid

• Do not discontinue surveillance at 5 years for stage I oral tongue cancer—projected 10-year disease-free survival is only 61% despite excellent overall survival of 89% 2
• Do not attribute new symptoms to "expected postoperative changes" without ruling out recurrence through examination and imaging 1
• Do not rely solely on patient-initiated visits—50% of local recurrences in early-stage disease were detected during routine follow-up visits rather than symptom-driven visits 3
• Recognize that revised negative margins after initial positive margins carry higher local recurrence risk (13.1% vs 5.5%) and warrant closer surveillance 5

Salvage Potential

• Local recurrence detected during surveillance has excellent salvage rates—50% of patients with local recurrence after stage I disease were successfully salvaged with surgery alone 2
• Early detection through systematic surveillance is critical, as 95% of recurrences are detected within 5 years but late failures beyond 3 years are common in stage I disease 1, 2
• Regional failure carries poor prognosis, emphasizing the importance of neck examination at each visit 2