BACKGROUND The margin status is an important prognosticator for the survival of patients with tongue cancer. Although a positive margin is associated with a poor prognosis, those with clear margins do not always have good clinical outcomes. METHODS We investigated the margin status, pattern of tumor invasion (POI), and tumor satellite distance (TSD) in 119 freshly treated tongue cancers and assessed their association with the characteristics and clinical outcomes. RESULTS A close or clear margin and POI were not associated with overall survival. Tumor satellites occurred in 92% of tumors and were significantly associated with betel nut exposure. Patients with TSD <or=0.5 mm had significantly better overall survival. Patients with TSD >0.5 mm had a higher incidence of local recurrence, shorter intervals to neck recurrence, and a higher propensity to contralateral or bilateral cervical nodal metastasis. CONCLUSION TSD is associated with local recurrence, contralateral neck metastasis, and the overall survival of patients with tongue cancer.