European Journal of Cardiovascular Medicine

Squamous cell carcinoma (SCC) accounts for more than 90% of all malignancies of the oral cavity, with the tongue being the most commonly affected subsite [1,2]. The mobile tongue is particularly vulnerable due to its thin non-keratinized epithelium, rich vascular supply, and extensive lymphatic drainage, which facilitate early tumor infiltration and cervical lymph node metastasis [3]. Tongue SCC is clinically significant because of its aggressive biological behavior, high recurrence rates, and profound impact on speech, swallowing, and overall quality of life.

Globally, cancers of the lip and oral cavity constitute a major oncologic burden. According to recent Global Cancer Observatory (GLOBOCAN) estimates, oral cavity cancers account for more than 400,000 new cases and approximately 200,000 deaths annually worldwide [4]. Squamous cell carcinoma of the tongue forms a substantial proportion of these cases. The burden is disproportionately higher in low- and middle-income countries, particularly in South and Southeast Asia, where exposure to tobacco, alcohol, and areca nut products is widespread [5].

India bears the highest global burden of oral cancer, contributing nearly one-third of all new cases worldwide [6]. The incidence of tongue cancer in India continues to rise, with many patients presenting at advanced stages due to delayed diagnosis, lack of awareness, socioeconomic constraints, and limited access to specialized healthcare services [7]. Data from the National Cancer Registry Programme indicate that cancers of the oral cavity are among the top three malignancies affecting Indian males, with tongue SCC being a leading contributor to cancer-related morbidity and mortality [8].

Tobacco smoking, smokeless tobacco use, alcohol consumption, and betel quid (pan) chewing are well-established etiological factors for tongue SCC, often acting synergistically to increase carcinogenic risk [9]. However, a growing incidence among younger patients and individuals without traditional risk factors has been reported, suggesting a role for genetic susceptibility, chronic mechanical irritation, viral oncogenesis, and molecular alterations in carcinogenesis [10].

Despite advances in diagnostic imaging, surgical techniques, reconstructive procedures, and adjuvant therapies, the overall survival rate for tongue SCC remains modest, largely due to advanced-stage presentation and early regional metastasis at diagnosis [11]. Management typically requires a multidisciplinary approach involving surgery, radiotherapy, chemotherapy, and comprehensive rehabilitative care.

The present article describes a case series of seven patients diagnosed with tongue SCC, reporting to a tertiary care medical hospital, highlighting diverse clinical presentations and disease stages. These cases are discussed alongside current concepts in surgical management, radiotherapy dose strategies, chemotherapy protocols, and emerging systemic therapies, with particular emphasis on relevance to the Indian clinical context.

Six male patients and one female patient presenting with ulcerative or ulceroproliferative lesions of the tongue were evaluated in the Department of Dental Surgery, tertiary care medical hospita. A detailed clinical history was obtained for each patient, including duration of symptoms, tobacco, alcohol, and pan chewing habits, and associated comorbidities. Thorough intraoral examination assessed lesion size, location, surface characteristics, induration, tongue mobility, and involvement of adjacent structures. Cervical lymph nodes were palpated and documented. Incisional biopsy was performed in all cases, and histopathological examination confirmed the diagnosis of squamous cell carcinoma. Clinical staging was estimated according to the American Joint Committee on Cancer (AJCC) 8th edition TNM classification. Relevant contemporary literature was reviewed to contextualize the clinical findings and discuss current treatment concepts. Case Series Case 1 A 42-year-old male with recently diagnosed type II diabetes mellitus presented with a non-healing ulcer on the left lateral border of the tongue of six months’ duration. The lesion initially appeared as a small ulcer and progressively increased in size. The patient had a history of smoking for 10 years and daily alcohol consumption for 20 years. Intraoral examination revealed an ulceroproliferative growth measuring approximately 5 × 4 cm on the left lateral border of the tongue. The surface appeared erythematous with irregular excrescences. Tongue mobility was preserved, and the floor of the mouth was free of involvement. No palpable cervical lymphadenopathy was noted. Case 2 A 51-year-old male reported a progressively enlarging ulcer on the left lateral border of the tongue for 10 months. The patient had a long-standing history of alcohol consumption but denied tobacco use. Initially asymptomatic, the lesion later interfered with mastication and dietary intake. Intraoral examination revealed an ulceroproliferative lesion measuring approximately 8 × 3 cm in the posterior part of the tongue, with raised everted margins and a slough-covered surface. Tongue movements were restricted, and the lesion was fixed to underlying tissues. A single fixed left submandibular lymph node was palpable. Case 3 A 59-year-old male presented with pain on the left side of the tongue for three weeks. The patient had no history of tobacco or alcohol use; however, a sharp cusp on the mandibular second molar was noted. Examination revealed an ulceroproliferative lesion on the left lateral border of the tongue with rolled-out margins and an indurated base. Tongue mobility was preserved, and no cervical lymphadenopathy was detected. Case 4 A 67-year-old male with a 15-year history of pan (betel quid) chewing presented with a non-healing ulcerative lesion on the right side of the tongue. Intraoral examination revealed a large ulceroproliferative growth involving the right dorsal and ventral surfaces of the tongue and extending to the floor of the mouth, measuring approximately 10x 8 cm. The lesion exhibited raised everted margins, areas of erythema, and yellowish necrotic slough. It was firm to hard in consistency with a markedly indurated base and was fixed to underlying tissues. Bleeding was elicited on manipulation. Palpable cervical lymph nodes were present. Case 5 A 33-year-old male presented with an extensive ulceroproliferative lesion involving the dorsum, right lateral border, ventral surface of the tongue, and extending to the floor of the mouth. The surface showed deep ulcerations with slough and fungal deposits. Tongue movements were markedly restricted, and fixed cervical lymph nodes were palpable. The patient reported weekend alcohol consumption and smokeless tobacco use for the past 10 years. Case 6 A 53-year-old female patient presented with an ulceroproliferative lesion on the right lateral border of the tongue. The lesion had raised, everted, rolled-out margins with an indurated base and was covered with slough. The patient denied any tobacco or alcohol habits, but sharp molar teeth were present. Tongue movements were normal, and no palpable cervical lymph nodes were detected. Case 7 A 61-year-old male with a history of smoking tobacco and alcohol consumption for 35 years reported to the department with a proliferative growth on the left side of the tongue. The lesion involved the dorsal surface and extended to the ventral surface. Palpable submandibular lymph nodes were noted, and the patient experienced pain during tongue movements.

Of the seven patients, six were male and one was female, with ages ranging from 33 to 67 years (mean age: 50.4 years). Lesions predominantly involved the lateral border of the tongue. Alcohol consumption was reported in four patients, tobacco use in four, and pan chewing in one. Restricted tongue mobility was observed in four cases, and cervical lymphadenopathy was present in five. Clinical staging ranged from Stage II to Stage IVA, with the majority of patients presenting with advanced disease. Histopathological examination confirmed squamous cell carcinoma in all cases.

Table 1: Clinicodemographic and Clinical Staging Summary

Figure 1: Clinical photographs of tongue squamous cell carcinoma showing ulceroproliferative lesions involving the lateral borders, dorsal and ventral surfaces of the tongue with varying extent, surface characteristics, and nodal involvement (Cases 1–7).

Squamous cell carcinoma of the tongue represents a biologically aggressive subset of oral cavity malignancies, characterized by early infiltration of intrinsic tongue musculature and a high propensity for cervical lymph node metastasis. The clinical profile observed in the present case series—male predominance, lateral border involvement, advanced tumor stage, and frequent nodal disease—mirrors epidemiological patterns reported globally and particularly within the Indian subcontinent [1–3].

The lateral border of the tongue is the most common site for SCC due to its thin non-keratinized epithelium and dense lymphatic drainage, facilitating early regional spread [4]. In the present series, all seven cases involved the lateral tongue, with four patients demonstrating impaired tongue mobility, a known surrogate marker for deep muscular invasion and advanced T stage [5]. Restricted tongue movement has also been correlated with increased risk of positive surgical margins and poorer locoregional control [6].

India bears a disproportionate burden of tongue and oral cancers, accounting for nearly one-third of global cases [2,3]. High prevalence of tobacco smoking, alcohol consumption, and areca nut (pan) chewing significantly increases cumulative carcinogenic exposure, explaining the high incidence and advanced stage at diagnosis [7]. Four patients in this series reported long-standing alcohol consumption, and had combined tobacco exposure, reinforcing the synergistic carcinogenic effect of these habits [8]. However, the occurrence of tongue SCC in a patient without identifiable risk factors (Case 3) highlights the emerging role of other etiological contributors such as chronic mechanical irritation, genetic susceptibility, and molecular alterations [9].

Late presentation remains a major challenge in tongue SCC management. Despite the tongue being easily accessible for clinical examination, lack of awareness, social stigma, and delay in seeking care result in advanced-stage disease at diagnosis [10]. In the present series, three of five patients presented with Stage IVA disease, consistent with Indian studies reporting advanced-stage presentation in 60–70% of oral cancer patients [11].

Surgical resection remains the cornerstone of curative treatment for resectable tongue SCC. Adequate oncologic clearance with negative margins and appropriate neck dissection is critical due to the high incidence of occult nodal metastasis, reported to be as high as 30% in clinically node-negative tongue cancers [12]. The landmark randomized trial by D’Cruz et al. demonstrated improved overall and disease-free survival with elective neck dissection compared to therapeutic neck dissection, supporting its routine use in early and advanced tongue SCC [13].

Postoperative radiotherapy (PORT) plays a vital role in improving locoregional control in patients with adverse pathological features such as advanced T stage, nodal metastasis, extracapsular extension, perineural invasion, lymphovascular invasion, and close or positive margins [14,15]. Concurrent postoperative chemoradiotherapy using platinum-based chemotherapy is recommended for high-risk patients, based on evidence from randomized trials demonstrating superior locoregional control and disease-free survival compared to radiotherapy alone [16].

Advances in radiotherapy delivery, particularly intensity-modulated radiotherapy (IMRT), have significantly reduced treatment-related morbidity while maintaining oncologic efficacy. IMRT allows superior dose conformity to complex target volumes and sparing of organs at risk, resulting in reduced xerostomia, dysphagia, and osteoradionecrosis—critical considerations in tongue cancer patients where functional outcomes are paramount [17,18].

Systemic therapy for tongue SCC continues to evolve. While cisplatin-based chemotherapy remains the standard radiosensitizer, recent advances in immunotherapy have transformed the management of recurrent and metastatic head and neck SCC. Immune checkpoint inhibitors targeting the PD-1/PD-L1 axis, such as pembrolizumab and nivolumab, have demonstrated survival benefits and are being actively explored in neoadjuvant and adjuvant settings for locally advanced disease [19–21]. Early trials have shown promising pathological response rates with neoadjuvant immunotherapy, although long-term survival data are awaited [22].

Functional impairment following treatment for tongue SCC significantly affects quality of life. Speech and swallowing dysfunction, nutritional compromise, and psychosocial distress are common sequelae, emphasizing the importance of multidisciplinary supportive care, including early nutritional intervention, speech and swallowing rehabilitation, and long-term follow-up [23,24].

Overall, the present case series reinforces the aggressive nature of tongue SCC, the predominance of advanced-stage disease at presentation, and the necessity for early detection and comprehensive multimodal treatment to improve survival and functional outcomes.

Clinical Significance

•             Persistent tongue ulcers must be biopsied promptly to avoid diagnostic delay

•             Advanced stage at presentation remains a major determinant of poor prognosis

•             Risk-adapted multimodal therapy is essential for optimal outcomes

•             Emerging immunotherapeutic approaches offer promise in selected patients

Tongue squamous cell carcinoma continues to pose a significant clinical challenge due to its aggressive behavior and frequent late-stage presentation. The present case series underscores the importance of early recognition, thorough clinical evaluation, and timely biopsy of suspicious tongue lesions. Optimal management requires a multidisciplinary approach integrating surgery, radiotherapy, chemotherapy, and rehabilitative care. Advances in radiotherapy techniques and systemic therapies, including immunotherapy, hold promise for improving survival and preserving function in patients with tongue SCC.

1.      Neville BW, Damm DD, Allen CM, Chi AC. Oral and Maxillofacial Pathology. 4th ed. Elsevier; 2016.

2.      Sung H, Ferlay J, Siegel RL, et al. Global cancer statistics 2020. CA Cancer J Clin. 2021;71:209–249.

3.      Bray F, Laversanne M, Sung H, et al. Global cancer statistics 2024. CA Cancer J Clin. 2024.

4.      Warnakulasuriya S. Global epidemiology of oral and oropharyngeal cancer. Oral Oncol. 2009;45:309–316.

5.      Woolgar JA. Histopathological prognosticators in oral and oropharyngeal SCC. Oral Oncol. 2006;42:229–239.

6.      Pentenero M, et al. Tongue mobility impairment and prognosis in OSCC. Head Neck. 2011;33:1450–1457.

7.      Gupta PC, Ray CS. Epidemiology of betel quid usage. Indian J Med Res. 2004;120:251–259.

8.      Hashibe M, et al. Alcohol and tobacco synergism in oral cancer. Cancer Epidemiol Biomarkers Prev. 2009;18:541–550.

9.      Llewellyn CD, Johnson NW, Warnakulasuriya S. Risk factors for oral cancer in young adults. Oral Oncol. 2001;37:401–418.

10.   Sankaranarayanan R, et al. Early detection of oral cancer. Oral Oncol. 2012;48:65–70.

11.   National Cancer Registry Programme. India cancer statistics 2023. ICMR.

12.   Shah JP, Gil Z. Current concepts in management of oral cancer. Surg Oncol. 2009;18:51–59.

13.   D’Cruz AK, et al. Elective versus therapeutic neck dissection. N Engl J Med. 2015;373:521–529.

14.   Cooper JS, et al. Postoperative chemoradiotherapy for high-risk head and neck cancer. N Engl J Med. 2004;350:1937–1944.

15.   Bernier J, et al. Defining risk levels in locally advanced head and neck cancers. Head Neck. 2005;27:843–850.

16.   Forastiere AA, et al. Concurrent chemotherapy and radiotherapy. J Clin Oncol. 2013;31:845–852.

17.   Nutting CM, et al. Parotid-sparing IMRT trial. Lancet Oncol. 2011;12:127–136.

18.   Gupta T, et al. IMRT in head and neck cancers. Radiother Oncol. 2012;104:343–349.

19.   Burtness B, et al. Pembrolizumab in recurrent/metastatic HNSCC. Lancet. 2019;394:1915–1928.

20.   Ferris RL, et al. Nivolumab for recurrent HNSCC. N Engl J Med. 2016;375:1856–1867.

21.   Uppaluri R, et al. Neoadjuvant immunotherapy in resectable HNSCC. Clin Cancer Res. 2020;26:5140–5152.

22.   Li G, et al. Neoadjuvant immunochemotherapy in OSCC. Front Immunol. 2025;16:118234.

23.   Elting LS, et al. Burden of oral mucositis. Cancer. 2008;113:2704–2713.

Logemann JA. Swallowing disorders following head and neck cancer. Otolaryngol Clin North Am. 2008;41:65–82.