How is tongue cancer diagnosed?

Dr Mark Torres-Holmes, a head and neck surgeon and ENT, details how tongue cancer develops and the method of diagnosis.

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There are so many parts of the body that you realise are important only when there is a problem and the tongue is no different. Imagine how getting tongue cancer would affect you? The tongue performs incredibly complex movements to speak, chew and swallow but when there is a tumour, you come to realise how a decrease in these functions would impact your quality of life.

All cancer is essentially a genetic disease, meaning that it involves mutation of genes. A higher risk of developing a mutation of certain genes can be hereditary which means that risk can be passed down among family members. Heredity alone though isn’t enough for patients to get tongue cancer.

The main reason cells develop gene mutations is related to carcinogens that are ingested. The most obvious are smoking or chewing tobacco, and alcohol. Smoking has a higher risk than alcohol but done together, risk is multiplied not added. Other causative factors include chronic inflammation, like poor dental hygiene, and other poorly understood conditions, such as leukoplakia (painless white patches on gums) and lichen planus (inflammatory condition of the skin and mucous membranes).

Signs and symptoms

Tongue cancer usually occurs between the ages of 60 – 80 years old, but can happen in people as young as 30. It often presents with a tongue ulcer that doesn’t heal within a month, usually on the side or the bottom surface of the tongue. Sometimes a lump or hard area can be felt and very little can be seen. It’s usually painful, worse with speech and chewing, with swallowing becoming affected the bigger it gets. Tongue cancers have a high chance of spreading to neck nodes, usually in level Ib (submandibular under the jaw) and level II (angle behind the jaw) and so a neck lump can also be a sign of trouble. 

Diagnosis

The first step in making a diagnosis is to seek help early, either with a general practitioner, dentist or ENT/head and neck surgeon. The second step is for the clinician to have a high index of suspicion for tongue cancer. A low threshold for biopsy if necessary, usually done under local anaesthetic. Sometimes examination and biopsy under anaesthesia is necessary due to pain or difficulty seeing the tumour. Histology is almost always a squamous cell carcinoma, originating from the surface lining of the tongue. Referral by the primary doctor to a head and neck multi-disciplinary team is likely to give the best survival and quality of life outcomes.

Assessing the size of the tumour and the structures involved are important for staging. Staging is helpful to guide decision-making and to give an idea of how difficult the cancer fight is going to be. The earlier the stage, the simpler the treatment and the better the outcome. The more advanced stage is when the tongue can’t move properly, the tumour is attached to the mandible or the cancer has spread to lymph nodes or the bloodstream.

We will often use radiological imaging to confirm the local stage as well as assess for nodal neck or distant metastases. The most common imaging techniques used are CT scans of the neck with contrast, sometimes to include the chest, but occasionally ultrasounds or MRI are used alone or in combination. For advanced disease, PET-CT is often necessary to check for spread to the lungs, bone or other internal organs.

Deciding on treatment

Once all the investigations have been performed, a decision is ready to be made. The best decisions are made in a multi-disciplinary team meeting, discussing the best scientific evidence to achieve the patient’s goals, and what the impact the treatment will have on the patient’s quality of life and ways to minimise that impact.

Header image by Freepik