Tongue Cancer

Tongue cancer is a type of mouth cancer. Tongue cancers are malignant tumors of the oral tongue in the mouth. The most common of these is squamous cell carcinoma of the tongue. Tongue squamous cell carcinoma develops from the thin, flat squamous cells that cover the surface of the tongue.

Tumors on the tongue most often occur on the sides of the tongue. The exact cause of tongue cancer is unknown. Tobacco use, alcohol consumption, tongue irritation, precancerous lesions of the tongue, and weakened immune system are important risk factors in the development of tongue cancers. Tongue cancers show signs and symptoms in the early stages. Avoiding risk factors is beneficial in tongue cancer prevention.

The diagnosis of tongue cancer can be made by biopsy. The chance of successful treatment and survival rate may vary depending on the stage and spread of cancer. The main treatments for tongue cancer are surgery, radiation therapy, and chemotherapy. If necessary, brachytherapy, targeted therapy, and immunotherapy can also be included.

Signs and Symptoms

Tongue cancers are malignant tumors of the front two-thirds part of the tongue in the mouth, also known as the oral tongue. Tongue cancers mostly occur on the sides of the tongue, close to the floor of the mouth. The probability of developing cancer from the tip and middle parts of the tongue is relatively less. Tongue cancers show signs and symptoms earlier because they are in an easily visible place.

Persistent lump or ulcer on the tongue

Tongue cancer can manifest itself as a lump or ulcer on the tongue that has existed for more than 2-3 weeks. Formations can bleed easily when touching or slightly biting. In particular, it should not confuse cancer-related tongue ulcers with oral aphthae. Oral aphthae get better in 2-3 weeks. They are harmless formations, they do not turn into cancer or do not become cancerous. Aphthae tend to shrink and disappear over time. On the contrary, tongue cancers do not shrink, do not disappear on their own, they continue to grow.

An enlarged or swollen tongue

Tongue cancer can also manifest itself as swelling of the tongue that has existed for more than 2-3 weeks. In particular, minor salivary gland tumors show symptoms like a swollen tongue rather than an ulcer.

Persistent patches on the tongue

Spots or patches on the tongue surface that are flat or raised for more than 2-3 weeks may be an early sign of tongue cancer. These formations can cause cancer of the tongue over time. Of these, leukoplakia is white patches on the tongue, erythroplakia is red patches on the tongue, and xeroderma pigmentosum is of varying shades.

A sore tongue that develops later

Tongue cancers are often painless at first. Over time, sore tongue and mouth pain is added to the symptoms. This increasing pain affects the patient’s speech, eating, and swallowing. The pain becomes increasingly constant and causes discomfort to the patient, especially at night. Therefore, not having pain at first does not mean that this formation of the tongue is not cancer. This feature distinguishes cancer of the tongue from oral aphthae, which are often painful from the start.

In summary, signs and symptoms of oral tongue cancer may include:
Persistent lump or ulcer on the tongue
An enlarged or swollen tongue
Persistent patches on the tongue
Easy bleeding when touched or bitten
A tingling or numb tongue
Difficulty moving the tongue
A sore or painful tongue
Pain while speaking and swallowing
Lump in the neck

Causes

It is not clear what causes tongue cancer. However, some well-known factors contribute to the development of tongue cancer. These factors are mainly intensive use of all kinds of tobacco, heavy alcohol consumption, tongue irritation, and precancerous tongue lesions. The role of human papillomavirus (HPV) in the development of oral tongue cancer is not clear.

Risk Factors

Tongue cancer is more common in older adults or older people. It is less common in women or young people. Male patients are typically people with tobacco use and excessive alcohol consumption, who do not pay much attention to oral hygiene. However, female patients may be individuals who do not use tobacco, don’t drink alcohol, and pay attention to oral hygiene. Tongue cancer rarely occurs in adolescents and children.

All forms of tobacco use

One of the most important factors for the development of tongue cancer is heavy smoking. Any use of tobacco, including chewing, is a serious risk in the development of tongue cancer. Tobacco contains many carcinogenic substances, mainly nitrosamines. These substances can change the normal structure of tongue cells and lead to cancer cell formation.

Excess alcohol consumption

Another very important factor in the development of tongue cancer is excess alcohol consumption. Alcohol turns into acetaldehyde, adversely affecting the DNA repair of cells. These cells that cannot be repaired can turn into cancer cells.

Irritation of the tongue

Jagged teeth and improperly fitting prostheses made of poor material can irritate the tongue, leading to the development of tongue cancer. There is some evidence in an experiment that mice had their tongues scratched and irritated, some of them developed tongue cancer.

Precancerous tongue lesions

Certain precancerous tongue lesions such as leukoplakia, erythroplakia, xeroderma pigmentosum in the form of flat or raised patches can cause tongue cancer over time. These formations may develop spontaneously or due to factors such as heavy smoking, alcohol consumption, tongue irritation, radiation. If such formations of the tongue are present for more than 2-3 weeks, it is necessary to treat it by removing it completely with surgery.

In summary, factors that may increase the risk of oral tongue cancer include:
All forms of tobacco use
Excess alcohol consumption
Jagged teeth and irritating dentures
Precancerous tongue lesions
Betel chewing (a common habit in the south and southeast Asia)
Exposure to particular chemicals
Exposure to radiation
A weakened immune system
Unhealthy and unnatural diet
Poor oral hygiene
Hereditary factors

Types of Tumors

Unfortunately, most of the tumors of the tongue are malignant. These are mainly squamous cell carcinoma and malignant minor salivary gland tumors.

Squamous cell carcinoma of the tongue

The most common cancer of the tongue is squamous cell carcinoma, also known as epidermoid carcinoma. Squamous cell carcinoma of the tongue develops from squamous cells, which are thin and squamous cells of the epithelial layer covering the tongue surface. Squamous cell carcinoma is also common in areas such as the mouth, nose, throat, pharynx, larynx, thyroid, respiratory and digestive tracts. Precancerous lesions of the mouth and tongue such as leukoplakia, erythroplakia, and xeroderma pigmentosum can also turn into squamous cell carcinoma over time.

Minor salivary gland tumors

There may also be malignant minor salivary gland tumors of the tongue such as mucoepidermoid carcinoma and adenoid cystic carcinoma. Both mucoepidermoid carcinoma and adenoid cystic carcinoma develop from microscopic salivary gland cells on the surface of the tongue. Mucoepidermoid carcinoma and adenoid cystic carcinoma show symptoms as swollen tongue rather than tongue ulcer.

Diagnosis

A patient who suspects tongue cancer should first consult an ear, nose, and throat doctor (otolaryngologist). To diagnose tongue cancer, the doctor first examines the patient’s tongue, mouth, throat, under chin, and neck. Later, the doctor takes tissue samples from the suspicious areas of the tongue for the pathologist to examine and various necessary imaging tests are performed.

Physical exam

The doctor first examines the ulcer, lump, swelling, or patches of the tongue under a strong light. By wearing gloves, the doctor checks the hardness of the lesion of the tongue and its spread to the tongue, mouth, or surrounding tissues. Then, the doctor examines the patient’s under-chin and neck lymph nodes.

Removing a tissue sample

The doctor takes tissue samples from the suspicious areas of the tongue and sends the samples to the pathology laboratory for the pathologist to examine. The doctor performs the tissue sampling (biopsy) under local anesthesia when necessary. A biopsy is not a procedure that causes the tongue tumor to spread. The diagnosis of tongue cancer is made according to the result of the pathologist examining the tissue samples.

Imaging tests

The tumor of the tongue may require imaging tests such as ultrasonography (USG), computerized tomography (CT), or magnetic resonance imaging (MRI) to be examined. To investigate whether the tongue tumor has spread to distant parts of the body, the doctor may need a positron emission tomography (PET) examination.

Treatment

The main treatment for tongue cancers is surgery. Treatment combinations including radiation therapy, chemotherapy, brachytherapy, targeted therapy, and immunotherapy are added to the treatment as needed. These treatments can be alone or combined according to the stage of the tongue cancer, the health status, and preferences of the patient. In cases where surgery is not possible for various reasons, other treatments may replace surgery.

Treating doctors

Otolaryngologists experienced in head and neck surgery, radiation oncologists applying radiation therapy, and medical oncologists applying chemotherapy often undertake the treatment of tongue cancers together. During or after the treatment of tongue cancer, dentists, psychiatrists, speech, nutrition, swallowing, and pain management specialists can also participate.

Surgery

Generally, the main treatment of tongue cancers is traditional oral surgery. TransOral Robotic Surgery (TORS) has no superiority over traditional surgery in areas that are easily accessible orally, such as the front and sides of the tongue and the floor of the mouth. TransOral Robotic Surgery is more advantageous in the surgery of areas that are difficult to reach orally, such as the base of the tongue.

Tumor removal

Removing non-spread, early-stage tongue cancers usually requires minor surgery. In particular, spread tongue cancers may require removal of a substantial part of the tongue (partial glossectomy) and sometimes the entire tongue (total glossectomy). The surgeon determines the amount of area on the tongue to remove with the tumor according to preoperative examination, biopsy, and imaging tests. Usually, the tongue tumor is removed with a safety margin, including some healthy tissue around it. The surgeon does this to make sure that no cancerous tissue is left behind.

Lymph node removal

During the surgery of tongue cancers, the surgeon removes the lymph nodes that are most likely to contain metastases in the neck through an incision made from the neck (neck dissection). The surgeon decides which of these lymph nodes to remove according to examination, biopsy, and imaging tests. Neck dissection is intended for treatment in cases where cancer has visibly spread to lymph nodes in the neck. Even if there is no metastasis, it is protective against future neck metastases.

Tongue reconstruction

During tongue cancer surgery, the surgeon takes control of biopsies from the parts adjacent to the removed area. After the pathologist reports that these tissue samples are clean, the surgeon begins to repair the tongue.

If the amount of tissue removed from the tongue and mouth is small, the remaining part of the tongue and other tissues in the mouth will be sufficient for repair. If the amount of tissue removed is large, the surgeon can take skin, muscle, and bone tissue (if the tumor has spread to the jawbone) from other parts of the body as needed. In this way, the surgeon repairs the gaps created when removing the tongue tumor and closes the incisions.

Normalization period after surgery

In the postoperative period, the patient may have drains, catheters, tubes that expel blood and fluid from the surgical wound. Depending on the size of the surgery, the patient may not be able to feed orally for a while. During this period, the patient feeds with special nutritional fluids from the vein or with the tube that extends from the nose to the stomach.

The patient also takes intravenous antibiotics and pain relievers to prevent possible infections and relieve pain. After the surgical wounds of the tongue and mouth have healed, the patient begins to feed orally with fluids and soft foods. After the patient can speak comfortably and eat normally, the hospitalization period ends.

Radiation therapy

Radiation therapy is the treatment that the radiation oncologist delivers to the patient for a certain period of time every day with a device that emits radiation. To apply this treatment, the patient must first recover after tongue surgery. Radiation therapy alone is not sufficient in the treatment of oral tongue cancers and is often added to surgical treatment.

However, in cases where surgery is not possible for various reasons, radiation therapy is often combined with chemotherapy (chemoradiation) to regress tongue cancer. Radiation therapy helps prevent the recurrence of late-stage tongue cancers after treatment. In this respect, radiation therapy is essentially a complement to surgery in the treatment of late-stage tongue cancers.

Brachytherapy

Radiation oncologists also deliver brachytherapy, a form of radiation therapy. Brachytherapy is suitable in cases where cancer of the tongue is still present after surgery and radiation treatments have been completed. Brachytherapy uses small tubes (implants) containing radioactive material. The radiation oncologist places these tubes around the cancerous tissues of the tongue for a certain period of time for treatment.

Chemotherapy

Medical oncologists administer chemotherapy by giving the patient strong anti-cancer drugs. These drugs reach cancer cells that have spread throughout the body through the bloodstream and neutralize them. Chemotherapy is an additional treatment to radiation therapy in the treatment of tongue cancers. Chemotherapy significantly increases the effectiveness of radiation therapy.

Targeted therapy

Medical oncologists also administer targeted therapy which mainly targets cancer cells. It uses drugs and substances that do little harm to healthy cells. Targeted therapy drugs act differently than traditional chemotherapy drugs. In addition, these drugs have different side effects than chemotherapy drugs and are usually milder. Targeted therapy is often combined with chemotherapy.

Immunotherapy

Immunotherapy aims to make our immune system more active against cancer by strengthening it. Because cancer cells desensitize immune system cells with some proteins they produce. In this case, the body’s immune system cannot attack cancer cells because it cannot see them. When tongue cancer progresses and other treatments are not an option, immunotherapy can be applied to the patient.

Speech functions after tongue cancer surgery

Language and mouth play an important role in the pronunciation of letters and words. Surgeries in these areas affect speech function. After the surgical wounds of the tongue and mouth of the patient heal, the speech becomes more easily understood. However, language plays an important role in the pronunciation of some letters. In this respect, the pronunciation of these letters may be less clear in the patient after part of the tongue is removed due to the tumor. In these cases, voice and speech therapists can assist the patient to deal with pronunciation problems.

Taste functions after tongue cancer treatment

Even if a part of the tongue is surgically removed, the remaining part of the tongue is sufficient for the taste function. Since the patient cannot feed orally in the first days after the surgery, it is not possible to taste. However, there is usually no problem in tasting after the treatments are over. But, patients who undergo radiation therapy after surgery may have taste disturbances and dry mouth due to the side effects of radiation. In these cases, ADA approved oral rinse (eg, Biotene Dry Mouth Oral Rinse, or as a different choice: TheraBreath Dry Mouth Oral Rinse, etc.) may be beneficial for the patient.

Feeding after tongue cancer surgery

For a while after surgery, the patient feeds intravenously with special nutritional fluids or with the help of a tube extending from the nose to the stomach. After the surgical wounds of the tongue and mouth heal, the patient begins to feed orally with liquid and soft foods. Over time, the patient normally feeds orally.

Prognosis

The incidence of tongue cancers has increased. Despite this, survival rates have also increased significantly. In particular, there is a high increase in survival rate in certain conditions, regardless of treatment. But survival rate varies with each stage of tongue cancer.

Treatment of tongue cancer is often possible. The success rate in treatment depends on the stage of the tongue cancer and how far it has spread. Especially in the early stages, the possibility of recovery of the patient is very high. Since tongue cancer is more likely to be detected in the early stages, the chance of success in treatment increases. Thus, in patients diagnosed with tongue cancer at an early stage, the disease has a very good prognosis.

Survival rates in tongue cancers in late stages may decrease according to the spread of cancer. Tongue cancers metastasize to the jawbone and distant regions such as the lungs and liver in the late stages.

Follow-up care

Even if the patient has received surgery, radiation therapy, chemotherapy, and other treatments, there is a risk of tongue cancer recurrence. Having all the necessary treatments in this respect does not reduce the possibility of recurrence of tongue cancer to zero, but can minimize it. The first year after treatment is the period when the cancer is most likely to recur. This possibility gradually decreases over the years.

Accordingly, the patient should come for regular check-ups at intervals determined by the doctor for up to 5 years after tongue cancer surgery. Recurrence of tongue cancer after the fifth year is, according to a generally accepted view, not coming back. This indicates a new cancer case in the same or close area.

Recurrence of tongue cancer

The recurrence of tongue cancer does not mean that the chances of a cure are over. In this case, the most important thing is to recognize recurrent cancer while it is in the curable stage and to take the necessary precautions. When tongue cancer recurs, the doctor first investigates whether repeat surgery is possible. If repeat surgery is not possible for the patient, low additional dose radiation therapy comes to the fore. Because a full dose of radiation therapy is usually only possible once effectively to a particular area. In this case, brachytherapy, another type of radiation therapy, is another option. In case of recurrence of tongue cancer, the patient may receive chemotherapy repeatedly, depending on the state of the immune system.

Prevention

Stop tobacco use

All forms of tobacco use, including smoking and chewing, should be avoided to reduce the risk of both developing and recurrence of tongue cancer. The person should stop using tobacco. If the person cannot quit smoking, a psychiatrist or psychologist can help.

Stop or limit alcohol consumption

To reduce the risk of developing tongue cancer, it is necessary to quit alcohol or limit its use. If quitting alcohol is not easy, alcohol rehab centers can help. Furthermore, the use of alcohol-containing oral care products is also risky. The use of them is regularly exposing the mouth to alcohol. In this respect, the use of alcohol-free products (eg, ADA approved mouthwash: TheraBreath Fresh Breath, CloSYS Sensitive Gentle Mint, CloSYS Ultra Sensitive Unflavored, or as a different choice: Tom’s of Maine Natural Wicked Fresh, etc.) is much safer.

Solve your dental problems

The person needs to have jagged teeth repaired, which is causing tongue irritation. It is necessary to replace the irritating dental prosthesis or dentures that are made of bad material or that do not fit the mouth properly.

Don’t scratch the tongue

It is necessary to be aware that scraping the tongue, even for cleaning purposes, is an inconvenient method and can cause tongue cancer. Instead of scraping the tongue, it will be healthier and safer to brush the tongue after brushing the teeth.

Have regular dental checkups

Tongue cancers normally occur in an easily visible part of the tongue. However, regular dental checkups can be useful for the early detection of precancerous tongue lesions, which initially seem harmless.

Live a healthy lifestyle

People who do not use tobacco, do not drink alcohol, and do not have any dental problems can also get tongue cancer. In this respect, it is important to give importance to oral hygiene, eat a healthy diet, exercise regularly, keep immunity and morale high to reduce the risk of developing tongue cancer.