DermaDiagnosis

He Needs More Than Lip Service for This Lesion

Publish date: August 10, 2021
Author(s):
Joe R. Monroe, MPAS, PA
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Lip lesion

Several years ago, the patient developed what he thought was a cold sore, which waxed and waned but never quite healed. It grew considerably over time but caused no pain, so the patient and his wife assumed it was benign. A few times over the years, his primary care provider (PCP) prescribed oral antibiotics, then later acyclovir, to treat the lesion. When it became large enough to interfere with normal speech, the patient’s PCP referred him to a dentist, who in turn arranged an urgent consultation with dermatology.

The patient was retired but had spent more than 50 years working and recreating outdoors without any protection. For 40 of those adult years, he had smoked. His health was good in other respects.

The 3-cm warty mass on the vermillion surface of the lower lip, just to the left of center, was focally eroded and quite firm to touch. Palpation of local nodal locations revealed several fixed nontender nodes, most notably in the submental area. His sun-exposed skin was quite sun damaged, with stellate scarring, abundant dyschromia, telangiectasias, and marked solar atrophy.

A 5-mm punch biopsy was performed, showing poorly differentiated squamous cell carcinoma.

Which of the following factors will impact this man’s prognosis?

Location

Delay in diagnosis

History of smoking

History of extensive UV exposure

Presence of palpable adenopathy

Poorly differentiated squamous cells

All the above

ANSWER

The correct answer is all of the above (choice “g”).

DISCUSSION

Squamous cell carcinoma (SCC) of the lip—almost always the lower lip—is quite common and appears to be caused by several factors. These can include exposure to ultraviolet light, ionizing radiation, arsenic (through contaminated groundwater or certain medications), tobacco, and human papillomavirus.

Early on in its manifestation, this patient’s SCC could have been excised with margins, producing an excellent prognosis. But with the extended delay in diagnosis and apparent related adenopathy, the patient’s future looked much less certain. At the very least, he would face extensive surgery, possible lymph node dissection, and maybe chemo and radiation therapies. Metastasis to the brain and lung(s) were very real possibilities.

The history associated with this case is far from uncommon, since these cancers are often mistaken for infection, which further delays correct diagnosis and treatment. Compounding this problem—and for reasons unclear to this author—affected patients are often referred to the wrong specialist. The critical missing piece of information was a diagnosis, which could only have been obtained through an incisional biopsy. Only then could the patient be referred appropriately.

Fortunately, in this case, the patient ended up under the care of a head and neck surgeon who planned to address this tumor after imaging of the head, neck, and lungs was completed.

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