Tongue cancer natural history, complications and prognosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Simrat Sarai, M.D. [2]

Overview

If left untreated, patients with tongue cancer may progress to develop metastasis. Common complications of treatment of tongue cancer include neurotoxicity, bleeding, radiation caries, trismus, osteonecrosis, oral mucositis, chronic dysphagia, anemia, pharyngocutaneous fistula, aspiration, infections, xerostomia, taste alterations, nutritional compromise, and abnormal tooth development. Prognosis is generally good, and the five-year mortality rate of patients with stage I and II tongue cancer is approximately 89 and 95 respectively. The five- year disease specific survival rate of patients with stage III and IV cancers is 39 and 27 percent respectively.

Natural History

• Carcinomas of the tongue base are clinically silent until they deeply infiltrate the tongue musculature. Tongue cancers usually present late, as they are usually painless and often ignored by the patient. Eventually they present as a non-healing ulcer which demonstrates growth over time.
• Due to the extensive lymphatic drainage of the tongue, nodal metastases are common at the time of diagnosis. A neck mass may therefore be the presenting complaint. Because of the difficulties with direct visualization, they may extend into the oral tongue or have clinical lymph metastases before the diagnosis is established.
• Tongue cancer often begins as a white patch, small lump, or sore on the tongue. Tongue cancer is often not diagnosed until it has grown and spread to other areas of the mouth, but if caught early it can be easily treatable. As the tumors enlarge, they may cause a mass effect which can lead to respiratory compromise when the patient presents late in their illness.

Complications

• Complications of chemotherapy includes the following:
  • Neurotoxicity- This complication is a side effect of certain classes of drugs, such as the vinca alkaloids.
  • Bleeding
• Complications of radiation therapy includes the following:
  • Radiation caries
  • Trismus
  • Osteonecrosis
  • Osteoradionecrosis
• Complications common to both chemotherapy and radiation include the following:
  • Oral mucositis
  • Chronic dysphagia
  • Anemia
  • Pharyngocutaneous fistula
  • Aspiration
  • Infections such as viral, bacterial, and fungal that results from myelosuppression, xerostomia, and damage to the mucosa from radiotherapy or chemotherapy
  • Xerostomia
  • Functional disabilities such as impaired ability to swallow, eat, taste and speak because of trismus, dry mouth, mucositis, and infection
  • Taste alterations such as changes in taste perception of food.
  • Nutritional compromise such as poor nutrition from eating difficulties caused by dry mouth, mucositis, dysphagia, and loss of taste.
  • Abnormal dental development
    • Altered tooth development, craniofacial growth, or skeletal development in children secondary to high doses of chemotherapy and/or radiotherapy before age 9.

Prognosis

The prognosis for patients with early oral cavity cancer [71].

The five-year overall survival rate was 70 percent.

Neck dissection was associated with an improved prognosis

a five-year relative survival for locally advanced oral cavity and oropharyngeal cancer of 54.7 percent [40 [41].

Lymph node involvement is the single most important prognostic factor for outcome in oral cavity cancer [42].

the number and size of positive lymph nodes

the presence of extracapsular extension  [46,47].

the ratio of positive lymph nodes to total number of excised lymph nodes [43-45]

• Depending on the extent of the tumor at the time of diagnosis, the prognosis may vary. However, the prognosis is generally regarded as good.
• The five-year mortality rate of patients with stage I and II cancers is 89 and 95 percent. The five-year survival rate calculated from a population-based database is reported as 67 and 51 percent respectively.
• The five-year disease specific survival rate of patients with stage III and IV cancers is 39 and 27 percent respectively. Cancer of the tongue has been associated with a worse prognosis compared with other oral cavity subsites in some series.
• In younger patients ie, less than 40 years, tongue cancer is found to have a more aggressive course.

• The prognosis of tongue cancer depends on the location and stage of the cancer.
• The five year survival rate for individuals diagnosed with Stage I, II, III, and IV is shown below:

Stage of the tongue cancer	Five-year survival rate
Stage I	71%
Stage II	59%
Stage III	47%
Stage IV	37%

• In 2011, approximately 25.69% of all oral cancer deaths were from tongue cancer. According to National Cancer Institute, from 2004-2008 the average age of death from tongue cancer was 66.

• Approximate age of diagnosis of tongue cancer and percentage of deaths from tongue cancer are shown below in this table:

Age of diagnosis of tongue cancer	Percentage of deaths from tongue cancer
≤20	0.1%
Age 20- 34	1.1%
Age 35- 44	3.9%
Age 45- 54	15.4%
Age 55- 64	24.8%
Age 65- 74	23.8%
Age 75- 84	20.3%
≥85	10.7%