Oral cancer, including cancer of the tongue, is more common and more dangerous than many people realize. Early signs are often first found during a routine dental exam, since people with tongue cancer may experience few symptoms.
"A person with tongue cancer would typically have no pain and may have a painless ulcer on the side of the tongue," says pathologist Manju Prasad, MD. Nationally, Yale Medicine is one the few academic medical centers with a dedicated pathology unit focused on cancers of the head and neck.
What is tongue cancer?
Tongue cancer (also known as mouth cancer) can start on the floor of the mouth, in the cells of the tongue, in the throat (at the base of the tongue) or anywhere in the mouth.
"A person with tongue cancer would typically have no pain and may have a painless ulcer on the side of the tongue," Dr. Prasad says.
How is tongue cancer diagnosed?
"Often the first sign is an ulcer on the side of the tongue that does not heal after a few weeks' time," says Dr. Prasad. In many cases, a dentist may detect suspicious precancerous lesions or sores at a routine cleaning and exam.
But an oral exam will only determine whether sores are present, not whether the lesions are cancerous. A definitive diagnosis requires a biopsy, which extracts abnormal cells and tests them for cancer.
How does a biopsy for tongue cancer work?
A biopsy may be performed by a dentist or by a doctor who specializes in mouth cancer diagnosis. This biopsy is an outpatient procedure (no anesthesia is required), in which a surgeon removes a small piece of tissue "just a few millimeters in size," explains Dr. Prasad. The specimen is then sent to the pathology lab, where a pathologist will analyze the cells under a microscope and make the initial diagnosis.
Then, says Dr. Prasad, "A lot depends on the answer to the initial question of whether this is cancer. In a sense, the biopsy results give the healthcare team marching orders on what to do next."
If cancer is detected, imaging tests – such as computerized tomography (CT) and magnetic resonance imagery (MRI) scans – are often ordered to determine its size. "In some cases, the full size of the growth can be hidden," Dr. Prasad says.
Imaging tests can also show whether the cancer has spread to bone and/or lungs. A follow-up procedure, called a surgical resection, will then be performed.
What is a surgical resection for tongue cancer?
Next, says Dr. Prasad, a surgical procedure will be done to remove the cancer. "Examination of the entire cancerous tissue will provide information that shows what stage the cancer is in – early to late – and determine prognosis and treatment options," he explains.
This is a more complex procedure than a biopsy, typically done under general anesthesia. The cancer is removed with the surrounding tissue to ensure a negative margin (no cancerous cells at the outer edge. This procedure can take several hours.
What does the pathologist do during and after the staging surgery for tongue cancer?
"During the surgical procedure, the pathologist is standing by to work with the surgeon to make sure no cancer is left behind,” says Dr. Prasad. “Yale Medicine uses rapid pathology, meaning that typically, within 10 to 15 minutes, a reading can be given to the surgeon, guiding him or her as to where there is additional cancer."
Once the surgery is complete, an even more thorough pathological evaluation can be performed.
"The tissue is analyzed in more detail, over several days, to determine the nature of the cancer, how aggressive or quiet it is," Dr. Prasad says. "The grading of the cancer and staging of the cancer also happens at this point, and these details, along with the expression of biomarkers to guide treatment, are contained in a pathology report."
How is tongue cancer treatment determined?
A multidisciplinary meeting is held with members of the Yale Medicine team, including the pathologist, oncologist, surgeon and radiologist. The team decides how aggressively to treat the cancer.
"The three most common modalities – radiation, chemotherapy and surgery – are frequently used in combination to control the cancer," says Dr. Prasad.
How does the work of the pathologist continue after the diagnosis of tongue cancer has been made?
On the front end of a treatment, a pathologist can inform the team which drug or therapy would be the most effective by looking for biomarkers – substances that can identify disease. For example, tongue cancers that are strongly positive for the biomarker p16 respond well to radiation and have a better outcome with lower dosage than p16-negative cancers.
"Pathologists may not see patients face to face,” observes Dr. Prasad, “but they are working closely with clinicians and oncologists behind the scenes to reach the best patient outcomes."
How is Yale Medicine’s approach to diagnosing tongue cancer unique?
Yale Medicine has a dedicated head and neck pathology service with specially trained, experienced pathologists who see a large volume of complex cases. They also have one of the few head and neck pathology training programs in the country. Our rapid pathology means that surgeons can receive fast test results – often within 10 to 15 minutes.
That means that, during surgery, there is less waiting around for test results while the patient is on the operating table. Another advantage of rapid intraoperative pathology is that it helps surgeons ensure that all cancer cells are removed. The likelihood of needing further surgery to remove additional cancer is far lower in patients treated with this advanced surgical technique.