Q. I have painless hard lump in my tongue for the past 2 years. Could this be cancerous?

Answered by
Dr. Vikas Talreja
and medically reviewed by Dr. Vinodhini. J
This is a premium question & answer published on Oct 09, 2020 and last reviewed on: Oct 19, 2020

Hi doctor,

I am a 28-year-old woman with history of smoking. I have lump inside my tongue for the past two years. The lump is not reaching the surface is just inside. I think it got bigger over the time but not rapidly. It is 6 mm big. I went to a doctor and they made a sonogram. The lump is in the middle of tongue, it is not painful and it is hard. I am in my first trimester of pregnancy. Doctors want to wait if it is get bigger to make fine needle biopsy. I am scared it can somehow put in danger. They want to do it without any local anesthetia. Sonogram doctor told me in his opinion that lump is not cancerous. I am scared that it will metastasis way down my lymph nodes. Should I wait or should I insist on that needle biopsy? Do you think is cancerous?



Welcome to icliniq.com.

May I look at lesion for better diagnosis and treatment, which includes a lot of differential diagnosis. White or red oral lesions include benign lesions (e.g., morsicatio buccarum and frictional keratosis, white sponge nevus [WSN]), benign lesions with malignant potential (eg. erythroplakia, leukoplakia, oral lichen planus and other lichenoid lesions, submucous fibrosis, actinic cheilitis).

For an oral lesion of less than three weeks duration, the acronym rule has been proposed as a practical clinical prediction rule for early detection of oral SCC (squamous cell carcinoma), red or red and white lesion, ulcer, lump, especially when in combination or if indurated (firm on palpation). Any lesions meeting these criteria should be regarded with suspicion and biopsied.

The main modifiable risk factors for oral SCC are tobacco use (smoked and smokeless), areca nut use, and alcohol consumption. The combined effect of alcohol and tobacco is greater than multiplicative for oral cavity cancer. However, oral cancer has been increasingly observed among subjects without any of the known modifiable risk factors.

The Probable causes:

Oral candidiasis is a common, opportunistic infection caused by intraoral, commensal yeast
atrophic glossitis.

Investigations to be done:

For all patients with an oral lesion, we perform a focused clinical history, with attention to the 1. Location of the lesion (e.g., the involvement of tongue only, all oral mucous membranes involved). 2. Color and quality of the lesion (hyperpigmented, erythematous, white, bullous, erosive/ulcerated, macular versus papular). 3. Duration of time the lesion has been present (if noticed). 4. Change in color or size of the lesion (eg, enlargement, waxing and waning of lesion size, periodic recurrence with resolution in-between episodes) 5. Associated local symptoms (bleeding, discharge, irritation, discomfort or pain, enlargement of local lymph nodes). 6. Systemic complaints (fever, rash, arthralgias or arthritis, unintentional weight loss). 7. Medications, including any recent medication changes and the use of any intraoral (topical) preparations. 8. Tobacco use (including smoking and smokeless tobacco products), enquiring about current use and tobacco history. In addition, we enquire about chewing betel quid, or paan (a combination of areca nut, spices, and tobacco that is popular in many parts of Asia). 9. Alcohol consumption, including current use and history of alcohol use. 10. Medical history, including any known autoimmune disease, malignancy (including history of previous bone marrow transplant), immunosuppression (infection with HIV, active cancer treatment, immunosuppressive medication). 11. Dental work, including the use of dental appliances (dentures) and the presence of amalgam fillings (silver fillings that contain elemental mercury).
Physical examination – In addition to the clinical history, we perform a careful intraoral and extraoral examination. Intraoral examination: we perform both a tactile and visual inspection of the oral cavity using gloved hands under adequate illumination. Before the examination, we ask patients to remove dental appliances (dentures), although examination with the appliance in place can also provide useful information, particularly when a traumatic lesion is suspected.

The oral lesion is carefully inspected with attention to the location, color, size, and quality (pigmented, ulcerated) and palpated for texture (soft versus indurated) and tenderness.
We then systematically examine all oral structures in a consistent sequence. We use both hands, utilizing gauze to grasp the tongue during the examination to adequately visualize the entire oral cavity and vestibule.

Extraoral examination: for all patients with oral lesions, in addition to a thorough intraoral examination, we perform a focused examination of the perioral area, including visual inspection of the lips and skin of the face and neck. Observation for any asymmetry, swelling, or masses of the face or neck. Palpation of head and neck lymph nodes, with particular attention to the anterior and posterior cervical, pre and postauricular, submandibular, submental, parotid, and buccal lymph nodes.

Differential diagnosis:

White or red oral lesions include benign lesions (morsicatio buccarum and frictional keratosis, white sponge nevus WSN), benign lesions with malignant potential (erythroplakia, leukoplakia, oral lichen planus and other lichenoid lesions, submucous fibrosis, actinic cheilitis). Oral candidiasis is a common, opportunistic infection caused by intraoral, commensal yeast.

Regarding follow up:

Follow up with the answers to the above questions and pictures of the photo taken.

Thank you doctor,

It is not seen outside, it is seen inside. It is firm and present for more than two years. It got bigger through time. It was 3 mm before, but now it is 6 mm large. We know it is not a cyst, following sonogram. It showed well-described borders like a small oval ball. I am pregnant now. Should I do a needle biopsy or should I wait? I have been to specialists, and they told me that I should wait until 11 weeks of my pregnancy. But I am scared it is malignant. On the other hand, they told me if it would be something aggressive, it should grow a lot faster than this. Please advise.



Welcome back to icliniq.com.

With the growth rate, as told by you over many years, chances of it being malignant are very less. Nonetheless, the biopsy is warranted for confirmation of nature. The best option is to get it done now and get relieved of the stress.

As I enumerated in my previous answer, there are various non-malignant causes of it. I suggest doing the biopsy now will relieve the stress at the back of your mind. The only way to confirm the nature of the lesion is by biopsy of the lesion.

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