Indurated ulcer of the lateral tongue in a smoker
58-year-old male
§Chief complaint
Painful ulcer on the side of the tongue that has not healed for 10 weeks
§Medical & dental history
- 0130 pack-year smoker, 25 units alcohol weekly
- 02Hypertension on amlodipine
- 03Partially dentate; no sharp restorations adjacent to the ulcer
§Clinical examination
- 01Ulcer 22 mm with rolled everted margins and a firm indurated base on the left lateral tongue
- 02Fixed to underlying muscle; restricted tongue protrusion to the left
- 03Single firm mobile 20 mm node at left level II
- 04No trismus; floor of mouth soft
§ figuresFigures (2)
Fig. 1Oral pseudomembranous candidiasis on the dorsum of the tongue
“Oral pseudomembranous candidiasis on the dorsum of the tongue of a 59-year-old male (third week of RT for a squamous cell carcinoma of the floor of the mouth, T3N0M0, daily dose 1.8 Gy)” · Ourania Nicolatou-Galitis et al. · CC0 · Wikimedia Commons
Fig. 2A large squamous cell carcinoma of the tongue
“SquamousCellCarcinomaTongueCT” · James Heilman, MD · CC BY-SA 4.0 · Wikimedia Commons
Verified open-access images only, reproduced for education under their stated licences · no AI-generated or illustrative artwork · Oral Squamous Cell Carcinoma figures pending faculty review.
§Differential diagnosis
§Final diagnosis
Moderately differentiated squamous cell carcinoma of the left lateral tongue, cT2 N1 M0
Induration, fixation and a non-healing ulcer over 3 weeks in a smoker/drinker is cancer until biopsy proves otherwise; histology showing invasive nests of malignant squamous epithelium with keratin pearls confirms it, and imaging stages the neck.
§Investigations
- 01Incisional biopsy from the ulcer edge including adjacent normal tissue
- 02MRI of tongue and neck for depth of invasion and nodal status
- 03CT chest and abdomen or PET-CT for distant staging
- 04Ultrasound-guided FNAC of the level II node — metastatic SCC
- 05Full blood count, nutritional assessment, dental clearance before radiotherapy
§Radiology
- 01MRI — tumour 24 mm with depth of invasion 9 mm, no mandibular involvement
- 02Neck ultrasound and CT — single 20 mm level II node with loss of hilar architecture
- 03CT chest — no metastases
§Treatment plan
- 01Multidisciplinary team discussion
- 02Wide local excision (partial glossectomy) with 10 mm clinical margins
- 03Ipsilateral selective neck dissection levels I-IV
- 04Reconstruction with radial forearm free flap; adjuvant radiotherapy based on pathology
- 05Speech and swallow rehabilitation; smoking and alcohol cessation support
§Surgical procedure
- 01Partial glossectomy with frozen-section margin control
- 02Selective neck dissection levels I-IV preserving XI, IJV and sternocleidomastoid
- 03Radial forearm free flap inset with microvascular anastomosis to the facial vessels
§Histopathology report
Moderately differentiated invasive squamous cell carcinoma with keratin pearls, depth of invasion 9 mm, perineural invasion present, no lymphovascular invasion; closest margin 6 mm. Two of 32 nodes positive at level II, no extranodal extension. pT2 pN2b.
§Follow-up & outcome
- 01Adjuvant radiotherapy 60 Gy completed at 12 weeks post-op
- 02Monthly review for the first year, then 2-3 monthly to year 2
- 03Thyroid function annually after neck irradiation
Outcome: No evidence of disease at 30 months; intelligible speech and oral diet maintained.
§Discussion
- 01Depth of invasion is now part of T staging — 5 mm and 10 mm thresholds upstage the tumour regardless of surface diameter.
- 02Elective neck dissection improves survival in clinically node-negative early oral cancer compared with watchful waiting.
- 03Perineural invasion, extranodal extension and close margins are the main triggers for adjuvant treatment.
§Clinical pearls / learning points
- 01Any oral ulcer persisting beyond 3 weeks needs a biopsy, not another course of antiseptic.
- 02Palpate for induration — it is a more reliable malignancy sign than appearance.
- 03Arrange dental assessment before radiotherapy to reduce osteoradionecrosis risk.
§Viva questions
What are the key prognostic histological factors in oral SCC?
Depth of invasion, margin status, differentiation, perineural and lymphovascular invasion, nodal metastasis and extranodal extension.
Which neck levels are dissected for an oral tongue cancer?
Levels I-IV in a selective supraomohyoid-extended dissection.
§MCQs
Q1Which feature most strongly suggests malignancy in an oral ulcer?
Q2Depth of invasion greater than 10 mm upstages an oral SCC to at least:
§ evidenceReferences & Evidence
Current Classification
WHO Classification of Head and Neck Tumours
5th Edition — Volume 9
WHO Classification of Tumours Editorial Board · 2022
The authoritative international classification of head and neck, odontogenic and salivary gland tumours. Current terminology on this site follows this edition.
Evidence summary
Highest level of evidence linked to this page: WHO / Official Classification.
- L1 · Classification — 2
- L3 · Systematic review — 2
- L4 · Research — 2
- L6 · Textbook — 3
2 linked sources were published from 2024 onwards. Where guidance is limited or contested, rely on the higher-level sources above rather than this summary. Educational use only — not a substitute for clinical judgement.
Content last reviewed
September 2026
Evidence last reviewed
September 2026
Next scheduled review
September 2027
Review status
EVIDENCE REVIEWED
Search latest PubMed evidence
Last literature search: 7 September 2026
Current Classification
WHO Classification of Tumours Editorial Board. IARC / World Health Organization · 2022
The authoritative international classification of head and neck, odontogenic and salivary gland tumours. Current terminology on this site follows this edition.
IARC / WHO. IARC · 2022
Continuously updated online edition of the WHO head and neck tumour classification.
Systematic Reviews & Meta-Analyses
de Almeida-Silva LA, Lupp JDS, Sobral-Silva LA et al.. Oral surgery, oral medicine, oral pathology and oral radiology · 2024 · 138(1):66-78
Systematic review of osteoradionecrosis incidence after intensity-modulated radiotherapy for oral cavity cancer.
Walsh T, Liu JL, Brocklehurst P et al.. The Cochrane database of systematic reviews · 2013 · 2013(11):CD010173
Cochrane review of conventional oral examination and adjuncts for detecting oral cancer and potentially malignant disorders.
Key Research
D'Cruz AK, Vaish R, Kapre N et al.. The New England journal of medicine · 2015 · 373(6):521-9
Randomised trial showing survival benefit of elective neck dissection over therapeutic dissection in node-negative oral cancer.
Ang KK, Harris J, Wheeler R et al.. The New England journal of medicine · 2010 · 363(1):24-35
RTOG 0129 analysis establishing HPV status as an independent prognostic factor in oropharyngeal carcinoma.
Histopathology References
Barnes L. CRC Press · 2008
Detailed histopathological reference for head and neck diagnostic criteria.
Textbook References
Neville BW, Damm DD, Allen CM et al.. Elsevier · 2024
Standard reference textbook of oral and maxillofacial pathology used throughout this atlas.
Rajendran R, Sivapathasundharam B. Elsevier · 2020
Undergraduate and postgraduate oral pathology textbook widely used in BDS and FCPS curricula.
Additional sources cited on this page
- D'Cruz AK et al. Elective versus therapeutic neck dissection in node-negative oral cancer. N Engl J Med 2015.
- AJCC Cancer Staging Manual, 8th edition.
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