Locoregional control of tongue cancer has improved. However, the incidence of distant metastases is rising, and a significant increase in long-term survival has failed to materialize. In our study, twenty-two (9.9%) of the 223 patients presented distant metastases. The incidence of distant metastases was significantly related to the tumor size and the regional lymph node involvement. Large (T4) lesions showed a higher risk for having distant metastases than T1-3 lesions (p < 0.01). The group with pathologic presence of disease in the neck lymph nodes had more than three times as many distant metastases as did those with pathologic absence (8.1% versus 26.8%). Moreover, 8 out of 13 (61.5%) patients with more than four pathological positive lymph node had distant metastasis. Tongue carcinoma patients with T4 lesion and four or more positive nodes had the highest risk of distant metastases and these patients may benefit from adjuvant systemic treatment.