Tongue Cancer Los Angeles Tongue Cancer Specialist
The tongue has several divisions: The oral part that includes the front 2/3 that is considered to be in the mouth and the back 1/3 that sits in the throat and is called the base of tongue (Fig. 1 Tongue). We will discuss the tumors in the oral or front portion in this section; base of tongue tumors behave very differently and will be discussed in another section (click on Base of Tongue on the right hand ruler to see more detail). The tongue is also divided in the center in two halves.
This is also an important division because the tumors that are limited to one side tend to only involve the lymph nodes on the same side of the neck while the tumors that cross this barrier may have involvement of lymph nodes on both sides
As mentioned before, most cancers of the tongue arise from the mucosal covering and not from the muscle underneath it, and they are called Squamous Cell Cancer (SCCA).
This is presumably because the mucosa that is covering is exposed to the environment and what enters our mouths that can cause cancer, while the muscle underneath does not get the same kind of exposure. However cancers of the mucosa of the tongue very easily grow into the muscle because the mucosa is thin.
Men are more often affected by cancer of the oral cavity than women. Cancer of the mouth is closely associated with cigarette smoking. Exposure to the chemicals in tobacco as they pass by the structures in the mouth, throat, voice box, and lungs is thought to lead to development of cancer. Tobacco and alcohol use each have been found to increase the risk by many folds (as high 20-30 folds). However, tobacco and alcohol use together can increase the risk of cancer by 70 folds. There is also an association with HPV (human papilloma virus) infection.
Symptoms and Diagnosis
Tongue cancer usually occurs in stages, by that I mean the tumor will usually first start as a small white or red discoloration on the surface. White lesions are called leukoplakia, and red lesions are called erythroplakia. These lesions can be at first not cancerous but be in the process of developing into a cancer. The red lesions have a much greater probability of becoming cancerous, however both white and red lesions have an unacceptably high risk and are worrisome; they need to be evaluated by a physician immediately. Often times if the lesion looks suspicious to your physician a biopsy will be performed (removal of a very small portion to look under the microscope). If a lesion is noted to change shape and size it must be biopsied immediately.(Fig. 3 Leukoplakia)
In the early stages of cancer the lesion often looks like a harmless sore. Sometimes these sores are painful, but often they cause no discomfort at all. Other symptoms may include bleeding, pain when chewing, and at times ear pain that is mild but persistent. (Fig. 4 Tongue Cancer Progression) It is important to see a physician if one notices any changes or new growths in the mouth. Regular visits to a dentist are important as well, as he or she will be sure to notice any suspicious changes. A biopsy is the only definitive test to diagnose cancer; no treatment can be started without a diagnosis.
In addition, diagnostic imaging may be required as well, such as a CAT Scan or MRI to check to see how deep into the muscle the cancer has grown (this may not be visible to the eye), as well as looking at the lymph nodes in the neck.
With larger tumors a PET Scan should be done as well to see whether the cancer has spread to the lymph nodes or other parts of the body. ( a.) CT Scan (b.) PET Scan (c.) Fusion of the two Scans
The TNM Staging is a universally used system based on size of the original tumor and involvement of the tissue next to it (T), the size and extent of lymph node involvement (N), and distant spread to other parts of the body or metastasis (M).
|T Stage||Primary Tumor|
|Tx||Primary Tumor Cannot be Assessed|
|Tis||Carcinoma in situ|
|T1||Tumor 2cm or less|
|T2||2 to 4 cm|
|T3||Greater than 4cm|
|T4a||Tumor Invades Adjacent Structures|
|T4b||Invades Masticator Space,Pterygoid Plates Skull Base or Encases Carotid Artery|
|M Stage||Distant Metastasis|
|Mx||Distant Metastasis Cannot be Assessed|
|M0||No Distant Metastasis|
|M1||Distant Metastasis Present|
|N Stage||Regional Lymph Nodes|
|Nx||Node Cannot be Assessed|
|N0||No Lymph Nodes|
|N1||Single Node Less than 3cm on the same side|
|N2a||Single Node 3 to 6 cm on the same side|
|N2b||Multiple Nodes Less than 6cm on the same side|
|N2c||Nodes on Both or Other Side Less than 6cm|
|N3||Node Larger than 6cm|
T1,T2,T3 or T4a
|IVc||Any T||Any N||M1|
The choice of treatment for tongue cancers is dependent on the stage, and more specifically the size, location, and the spread of tumor. Tongue cancers can be very misleading, and could be more aggressive than they appear. Most tumors require two modes of therapy and in the very advanced tumors even three modes of therapy. The three available therapies (modes of therapy) are surgery, radiation therapy, and chemotherapy.
This is a very complex subject, but we will try to simplify it here as much as possible by stating some simple facts: First, chemotherapy alone cannot cure squamous cell cancer; chemotherapy is given in combination with radiation therapy, and in doing so it makes the radiation therapy more effective. Second, radiation alone and surgery alone can only be used for the very small lesions that have not shown signs of spread. Third, if possible surgery should be used as one of the modes of therapy as improves the cure rate to a great degree. Patients who have surgery will continue to speak and eat normally if the procedure is done by expert head & neck cancer surgeons and reconstructed appropriately.
Tongue cancers in a majority of cases are curable and there is great hope. At the center we see patients with tongue cancer frequently. This is a very aggressive and potentially deadly cancer, do not take this tumor lightly and if your physician tells you that you just need a minor surgery and that is it, seek a second opinion. We confront this situation on a frequent basis where the patient is told not only by surgeons but also oncologists and radiation oncologists that their tongue cancer is simple and that they don’t need to be aggressive. It is a rare and fortunate occurrence when the tongue cancer is small enough for surgery alone or radiation alone to be adequate. If the tumor is this small it is better to treat it surgically because the side effects of surgery are minimal and much less than radiation therapy.
Most common and effective mode of therapy is surgery followed by radiation therapy. In the more advanced cases, surgery is followed by both chemotherapy and radiation. Chemotherapy and radiation alone are only used for patients that cannot have surgery either because of health reasons or if the tumor is too large to remove. Our team of doctors evaluates each case thoroughly, a patient is seen by a head & neck surgeon as well as reconstructive surgeon, to plan an appropriate surgical plan. Surgical expertise is extremely important in both improving cure rates and speech and swallowing function. A variety of surgeries and surgical approaches are available, including partial & hemi-glossectomy, and laser resection accompanied by a neck dissection (in most cases); this is followed by appropriate reconstructive measures from skin grafting to free flap reconstruction. An amount of tongue that needs to be removed is dictated by the tumor, but as much as 2/3 of the tongue can be removed, and if reconstructed appropriately, the patient can speak and eat fairly normally.
Radial Forearm Free Flap
We will work with your oncologist and radiation oncologists or if you don’t have these physicians we will make such a team of doctors for you. Bear in mind, this tumor is extremely aggressive and time is of the essence. Before treatment begins all patients will need to be seen by their dentist in preparation for their course of therapy. After surgery therapy to resume speech and swallowing, if needed, will begin right away. Our speech and swallowing outcomes are excellent. The most important aspect of therapy is having an experienced team that you trust.