Ask Dr. HKSH – Tongue Cancer

Dr. William I. WEI

Specialist in Otorhinolaryngology

Q1. What are the symptoms of tongue cancer?

The most common symptoms of tongue cancer are ulcers or small sores on the tongue. They may remain unhealed for a long time. While early tongue cancer may not cause pain, bleeding may occur from time to time. A lump or swelling may also appear near the ulcer. These are typical early signs of tongue cancer. In the late stage, cancer cells may spread and metastasise to the neck lymph nodes. The lymph nodes in the neck may become enlarged, and the tumour in the mouth may grow bigger and bigger, causing swallowing difficulties and slurred speech.  These are the signs of advanced tongue cancer.

Q2. Who is more likely to get tongue cancer?

There are five common risk factors for tongue cancer. They all start with the letter "S". Smoking: People who smoke regularly. Spirit (alcohol): People who often drink strong alcohol (spirits). Spices: Not just chilli, but also irritating foods, such as betel nuts. Sepsis: Chronic inflammation or infection due to poor oral hygiene, which is especially common in street sleepers as they seldom brush teeth. They are at higher risk of developing tongue cancer. Sharp tooth: Sharp or jagged teeth may rub against the tongue for a long time, including poorly fitted dentures, sharply edged or crooked teeth. If this continues for years without treatment, it may lead to a tumour.

Q3. How is tongue cancer diagnosed? How is it staged?

If a tongue ulcer remains unhealed for a long time, and there is a lump nearby, a biopsy should be done to check for tongue cancer. A small piece of tissue will be taken from the ulcer and sent for laboratory testing. A fine needle aspiration may also be performed in neck lymph nodes to check for cancer spread and determine cancer staging.

Just like other cancers, tongue cancer is divided into stage 1 to 4. Staging depends on tumour size: it is usually in stage 2 if larger than 2cm, and stage 1 if smaller than 2cm. A stage 3 tumour is one that exceeds 4 cm in size.

The latest staging method considers both tumour size and thickness: a stage 2 tumour is thicker than 5mm, while in stage 3 it is often thicker than 10mm. Of course, it indicates a higher stage if cancer cells are also found in neck lymph nodes.

Q4. How is tongue cancer treated? Why are the lymph nodes also removed in surgery?

To completely cure tongue cancer, surgery is the main treatment. The tumour is removed together with some surrounding tissues, usually within a margin of about 1 to 1.5cm around the tumour. This is because tongue cancer often spreads wider than what it appears to naked eye. The visible tumour is only part of the actual cancer. Therefore, a slightly bigger area is usually removed. Don’t worry - the tongue can be repaired after operation. Most patients can speak and eat without major problems afterwards.

Apart from the tongue cancer itself, the neck lymph nodes may also need to be removed as indicated by tumour stage and thickness. If the tumour is thin (less than 3mm thick), the chance of cancer spreading to the neck lymph nodes is low — usually less than 10%. Neck lymph node removal is often not necessary. But if the tumour is thick (9 mm or more, about 1 cm thick), the risk of cancer spreading to the lymph nodes increases to around 33%. Therefore, in case of thicker tumours, neck lymph nodes, even not palpable, are also removed during surgery to achieve the best chance of complete cure.

Q5. Will the cancer come back after surgery? How does partial tongue removal affect one’s daily life?

If the tumour is completely removed, the chance of recurrence is low. 95% of tongue cancers spread within 1 to 1.5cm around the main tumour. While removing this amount of tissue usually gives a good chance of cure, about 4 cm around the tumour, or almost the entire tongue, may need to be removed to eradicate all tumours. Therefore very few patients opt for total tongue removal.

The recurrence rate is about 5% if the tumour is removed along with a 1 to 1.5cm margin. This keeps the removed portion relatively small but still offers a high chance of cure. If about half the tongue is removed, the wound can usually be closed with stitches. Speech and eating functions can achieve about 80% to 90% recovery within one year after surgery. If a larger portion, or even over half of the tongue is removed with other parts of the oral cavity, the wound may become too large to close with stitches. Reconstruction using skin grafts or flaps will be needed. And one can still recover up to 70 to 80% of eating and speech functions afterwards.