Long Case History: Carcinoma of the Lateral Border of the Tongue

PATIENT PROFILE

CHIEF COMPLAINTS

1. Swelling on the lateral part of the tongue — since 6 months
2. Pain in the tongue — since 4 months
3. Difficulty while eating and swallowing food (dysphagia/odynophagia) — since 2 months
4. Difficulty in speech (dysarthria) — since 2 months

HISTORY OF PRESENT ILLNESS

• Difficulty in eating — chewing became painful and difficult; she was now eating only soft or liquid food
• Dysphagia — difficulty swallowing solid food, later progressing to semi-solids
• Dysarthria — speech became slurred and unclear, with difficulty pronouncing lingual sounds (letters involving tongue tip and blade movements)
• Odynophagia — pain on swallowing

• Halitosis (foul smell from the mouth)
• Excessive salivation / drooling
• Significant weight loss (approximately 5–7 kg over 4 months)
• Reduced appetite

HISTORY OF PAST ILLNESS

• No similar complaints in the past
• History of chronic oral submucous fibrosis — present (she noticed restricted mouth opening 2–3 years ago, attributed to betel nut chewing)
• History of leukoplakia on the buccal mucosa noticed by dentist approximately 1 year ago — no biopsy done
• No history of tuberculosis, diabetes mellitus, hypertension, epilepsy, or asthma
• No prior surgeries or hospitalizations
• No known drug allergies

PERSONAL HISTORY

Combined tobacco and alcohol use synergistically increases the risk of head and neck cancer by up to 45 times more than either alone. — Sabiston Textbook of Surgery

FAMILY HISTORY

• No similar illness in family members
• No history of malignancy in immediate family
• No consanguineous marriage

SOCIOECONOMIC HISTORY

• Lower middle-class family
• Lives in a joint family setup
• Husband is a daily wage laborer
• No health insurance
• Access to medical care is limited; patient sought care only when symptoms became debilitating

GENERAL PHYSICAL EXAMINATION

LOCAL EXAMINATION

Extra-oral Examination

• Face: Asymmetrical — mild fullness on the right side of the floor of the mouth region
• Mouth opening (inter-incisal distance): Reduced (~3 cm — mild trismus); limited mouth opening due to oral submucous fibrosis
• Temporomandibular joints: No tenderness, no clicking
• Lips: Dry, no ulcers, no fissures
• Skin overlying the jaw: Normal

Lymph Node Examination (Neck)

• Right submandibular nodes (Level IA/IB): 1 node palpable, approximately 2 × 2 cm, firm, non-tender, mobile — likely metastatic
• Right upper deep cervical / jugulodigastric (Level II): 1 node palpable, approximately 1.5 × 1 cm, firm, non-tender
• Left side: No palpable nodes
• Posterior triangle / other levels: Not palpable

Regional metastases of oral tongue cancer primarily drain to levels I–III. The incidence of clinically detectable nodal metastases is 25–33%, with another 20–25% occult. — K.J. Lee's Essential Otolaryngology

Intra-oral Examination

Tongue Examination

PROVISIONAL DIAGNOSIS

DIFFERENTIAL DIAGNOSES

1. Squamous Cell Carcinoma of the tongue (most likely)
2. Traumatic ulcer (chronic irritation from sharp tooth — but this does not explain progressive induration and cervical lymphadenopathy)
3. Tuberculous ulcer of the tongue (undermined, irregular edges — but no systemic features of TB)
4. Syphilitic ulcer (painless, indurated — but no other syphilitic features)
5. Non-Hodgkin's lymphoma (uncommon; usually nodular)
6. Granulomatous disease (Wegener's, Crohn's)
7. Salivary gland tumor (uncommon at lateral border)

"Rarer causes of chronic oral ulcer, such as tuberculosis, fungal infection, granulomatosis with polyangiitis, and midline granuloma may look identical to carcinoma." — Harrison's Principles of Internal Medicine, 22nd Ed.

INVESTIGATIONS

Routine

Specific

STAGING (AJCC 8th Edition)

AJCC 8th edition incorporated depth of invasion (DOI) as an independent T-staging criterion. Depth >4 mm correlates with higher regional metastasis rates and mortality. — Sabiston Textbook of Surgery

MANAGEMENT PLAN

Immediate

• Analgesics for pain control (Non-opioid initially; escalate as needed per WHO pain ladder)
• Nutritional support — high-protein, high-calorie liquid diet; consider nasogastric feeding if oral intake critically impaired
• Oral hygiene improvement
• Multidisciplinary tumor board referral (Head & Neck Surgery, Radiation Oncology, Medical Oncology)

Definitive Treatment

• Partial glossectomy (hemi-glossectomy) with adequate margins
• Reconstruction: Primary closure / skin graft / radial forearm free flap (depending on defect size)
• Selective or modified radical neck dissection (ipsilateral levels I–III) — for clinically N1 disease and elective treatment of contralateral occult nodes if midline involvement
• Mandibulotomy if access is required; marginal or segmental mandibulectomy if bone is involved

• Post-operative radiotherapy (PORT): for close/positive margins, perineural invasion, lymphovascular invasion, N2/N3 disease
• Concurrent chemoradiotherapy (cisplatin-based) if extranodal extension or positive margins

"For T4 tongue cancers, chemoradiation may be considered. However, bone involvement usually requires surgical resection." — K.J. Lee's Essential Otolaryngology

Rehabilitation

• Speech therapy — speech and swallowing rehabilitation post-surgery
• Swallowing therapy / diet modification — gradual progression from liquid to semisolid to solid diet
• Gastrostomy tube if persistent post-operative dysphagia (~17% of free-flap reconstruction patients may remain G-tube dependent)
• Dental rehabilitation — dentures, jaw exercises
• Psychological support and counseling — regarding diagnosis, prognosis, body image

PROGNOSIS

• Prognosis worsens with: depth of invasion >4 mm, perineural invasion, mandibular involvement, extranodal extension, and bilateral cervical lymphadenopathy.
• Surveillance post-treatment: Every 1–3 months in year 1; every 2–6 months in year 2; every 4–8 months in years 3–5. Imaging within first 6 months post-treatment. The majority of recurrences (80–90%) occur within 2 years.

— Sabiston Textbook of Surgery; K.J. Lee's Essential Otolaryngology; Harrison's Principles of Internal Medicine, 22nd Ed.

SUMMARY