How would you treat a symptomatic tongue metastasis?

It is a very broad question. Assuming wide spread mets from a subclavicular primary, I tend to favor standard palliative regimens, and in head and neck sites, I find a quad shot with potential for repeating 1 or 2 times if responsive, very appealing, especially in patients with poorer PS/poor prognoses (i.e., exhausted systemic options), and/or logistical challenges. If a more favorable scenario, I might use a more aggressive, but not very protracted regimen; I do think when we use these more aggressive regimens for "palliation" with a goal for longer term control, we do make the patients more miserable in the short run with mucositis, and we don't recognize this because of the "out of sight, out of mind" phenomenon, of these short large fraction regimens.

When treating for palliation, I treat the tumor only; I do not add subclinical dose or chase uninvolved nodes.

Depends on what primary histology is, other Mets, rate of disease progression, if other treatments are available…there’s a lot to consider before deciding how to treat. So we need to know more. But, in general: if it’s isolated met, would think about SBRT using 35-40 Gy in five fractions. If diffuse disease and not long to live, would do a simpler treatment, maybe 5-6 Gy X 5.