A 60-year-old man comes to the office due to a sore on his lip. He has a 3-month history of an enlarging lesion on his lower lip associated with ulceration and slight pain. Past medical history is unremarkable. The patient does not use alcohol, tobacco, or illicit drugs. He works as a farmer and has no new sexual contacts. Vital signs are normal. Examination shows a 3×7-mm partially encrusted ulcer in the vermilion zone of the lower lip, surrounded by a 6×12-mm area of induration. There are no palpable submental or submandibular lymph nodes, and the remainder of the physical examination is unremarkable. Biopsy of this lesion will most likely show which of the following?

Question

A 60-year-old man comes to the office due to a sore on his lip.  He has a 3-month history of an enlarging lesion on his lower lip associated with ulceration and slight pain.  Past medical history is unremarkable.  The patient does not use alcohol, tobacco, or illicit drugs.  He works as a farmer and has no new sexual contacts.  Vital signs are normal.  Examination shows a 3×7-mm partially encrusted ulcer in the vermilion zone of the lower lip, surrounded by a 6×12-mm area of induration.  There are no palpable submental or submandibular lymph nodes, and the remainder of the physical examination is unremarkable.  Biopsy of this lesion will most likely show which of the following?

Quizplus · Accepted Answer

This patient, who has an outdoor occupation with significant sun exposure (farming) and who has developed a persistent, indurated, ulcerating lower lip lesion, has typical features of squamous cell carcinoma (SCC). SCC is the most common malignancy of the lip, with 95% of cases occurring in the lower lip vermilion, likely due to higher exposure to sunlight. In addition to ultraviolet (eg, sunlight) exposure, other risk factors for SCC include fair skin tone, tobacco use (smoking or chewing), heavy alcohol use, chronic inflammation or scar formation, and immunosuppression. Diagnosis of SCC is confirmed with biopsy. Typical pathologic findings include invasive cords of squamous cells with keratin pearls. Prognosis is usually very good for cutaneous SCC, with curative resection seen in >90% of patients. Most lesions do not metastasize, but untreated SCC can cause extensive local destruction and may eventually spread to local lymph nodes or distant structures. Adverse prognostic features include larger size, deeper invasion, and involvement of regional lymph nodes. keratin pearls (Choice A) A Tzanck preparation of vesicular fluid can identify the characteristic giant cells of herpes simplex virus (HSV) infection. HSV can cause recurrent labial or peri-oral ulcerating lesions, but these usually resolve within 2 weeks. lesions (Choice B) Granulomatous ulcers can be seen in a number of disorders, such as tertiary syphilis, tuberculosis, or disseminated fungal disease. However, most patients with these conditions would have additional systemic (eg, fever, night sweats in tuberculosis) or local (eg, genital lesions in syphilis) symptoms or known immunocompromised states. (Choice D) Basal cell carcinoma (BCC) is characterized histologically by invasive clusters of spindle cells surrounded by palisaded basal cells. Like SCC, BCC can form ulcerating lesions and is associated with sun exposure. However, BCC of the lip is much less common than SCC and typically affects the upper rather than lower lip. (Choice E) Aphthous ulcers (canker sores) are characterized by shallow, fibrin-coated ulcerations with underlying mononuclear infiltrates. They are recurrent, self-limiting ulcerations of the oral cavity and do not affect surfaces covered by keratinized stratified squamous epithelium. Educational objective: Squamous cell carcinoma is the most common malignancy of the lower lip. Risk factors include sun exposure, fair skin, tobacco use, immunosuppression, and chronic inflammation. Biopsy is characterized by invasive cords of squamous cells with keratin pearls. References: Treatment of squamous cell carcinoma of the lip. (http://www.ncbi.nlm.nih.gov/pubmed/19140283)

A 60-Year-Old Man Comes to the Office Due to a Sore