Case discussion: How would you treat this patient? [28 September]

This week we feature a case from Dr Alex Speight. Please read his comments on the case below:

“39 year-old man came to my practice as a new patient. He had seen a doctor elsewhere in May 2019 for a small lip lesion which was not healing. According to the patient, they biopsied it, then offered cryotherapy. The patient declined and did not see them again. The lesion has since grown. The patient said he has since reportedly seen two doctors who did not suggest doing anything.”

Below is the original biopsy result. How do you interpret this biopsy?

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Case discussion

Update 1:

This is what the lesion looks like now. What is going on here? What would you do?

Case discussion    Case discussion

Update 2:

Here is the pathology result. What next?

CLINICAL NOTES:
Histology
Right lower lip growing lesion > 1 year, not healing, keratotic. r/o scc
Very friable, attempted 8mm punch bx

MACROSCOPY:
Right lower lip: The specimen contains multiple fragments of cream red tissue measuring in aggregate approximately 15x7x5mm. All blocked in toto, 1 block. (JF/psh)

MICROSCOPY:
The partially fragmented biopsy material shows A WELL DIFFERENTIATED SQUAMOUS CELL CARCINOMA measuring 1.9mm in depth. The tumour is extensively inflamed.

CONCLUSION:
RIGHT LOWER LIP, EXCISION:
– WELL DIFFERENTIATED SQUAMOUS CELL CARCINOMA (SCC)

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26 comments on “Case discussion: How would you treat this patient? [28 September]

  1. No healing lesion needs a further biopsy and I would in any case ask the pathologist who processed the first biopsy to please review it .

  2. strong suspicion of SCC.
    it was 2 mm biopsy. (not an excisional biopsy)
    repeat biopsy with bigger punch/ excisional biopsy.

  3. Our local pathology many years ago sent around a circular asking doctors not to do punch biopsies any smaller than 4mm minimum and preferably bigger, 5 or 6mm. This was a 2mm punch.

    The reason is that there is insufficient material for examination, and such small specimens are prone to damage artifact simply because of there size.

    So you can’t draw a conclusion on this specimen more tissue is needed.

    Squamous proliferation and an enlarging lesion is suspicious. Especially if a smoker (we don’t know that).

    If confident with lip surgery excise the entire lesion. Otherwise ask someone to do that for you.

    1. Agree with you Andrew. Larger tissue would have aided pathologist.
      Would suggest excision biopsy be next as both diagnostic and possibly therapeutic now given time frame of lesion. If unable, refer to a colleague or plastics.

  4. Agree 2mm punch not acceptable. Would strongly advise pt of risk of a missed SCC left undiagnosed and untreated. Show pt some horrible images of neglected SCC’s on lips to help persuade him to have a proper biopsy and Rx.
    If all that fails, get him to sign document stating that he has refused further biopsy and ditto refusing any other Rx at his own risk.

  5. I think the pathologist tries to tell you that he concludes it is actinic keratosis and not SCCis (in not very clear words – bit confusing terminology). If in doubt, consider giving him a phone call. I`d advise daily sunprotection – f.e. zinc based lip balm sticks.
    Any other treatment seems optional – and will likely go with significant discomfort. Cryo could be an option if it`s a small area.

  6. solar keratosis on lip, can use cryo sequentially over 2 weeks to treat this or else Aldara thrice a week for 2 weeks

  7. First need to know if patient is a smoker or not
    If has any other skin cancer in the past
    Second not sure 2mm punch biopsy is enough to diagnose SCC
    Third if we thinking is simple ulcer or chronic sunburns then we try to see healing with other option of treatment
    Fourth if is SCC then we need to talk to plastic dr and do excision biopsy

  8. SCC clinically and dermoscopically; pink tumour with white circles & overlying keratin masses.

    Will need an excisional biopsy by oral / plastic surgeon & further treatment pending pathologist review.

  9. I fear it may be too late for this man given the 18 month delay in diagnosis.
    This is an aggressive SCC until proven otherwise by dermatopathology of the whole lesion.The history,macroscopic appearance and dermatoscopic findings all suggest this.Generous wedge excision done by whoever you think is competant—-plastic surgeon,Mohs surgeon,or skilled GP colleague.This has to be treated as a skin cancer emergency.Andrew and Raph are right in their assessments.

  10. I agree with the concern that the biopsy is too small. Not sure if 3 mm is sufficient or whether it should be 4 mm as I have been hearing conflicting advise in that regards and would like to hear the recommendation from Health Cert.
    Any non healing lesion on a sun exposed is a skin cancer until proven otherwise and this particular lesion looks bad, even without the dermatoscope. I am very concerned this man has a neglected SCC…

  11. Looks like a punch excision was done initially and was reported as non cancerous. I would consider this a lesion arising in a previously treated area and highly suspicious of NMSC. I would do a punch biopsy, at least 3-4 mm and give the pathologist the history of a lesion arising in a previous scar.

  12. None healing lesion ,high risk skin type,dermatosvopy ? SCC. Need 3-4 mm punch to confirm. Then definitive surgery depending on diagnosis and extension/staging.

  13. Is he a smoker? Squamous hyperplastic change is a risk for SCC. This lesion needs to be excised with adequate margins. Also feel for locoregional lymphadenopathy. Early on, the biopsy may have been more helpful if it was larger; I would always follow up someone with squamous hyperplasia, especially if they declined treatment. The original presentation was a non-healing sore, which is always suspicious for malignancy.

  14. Thanks everyone. I see this situation quite often, which is sad. As you have indicated, the first problem here is that the first punch was too small – 2mm is just not enough. And, second, the first doctor accepted the pathology result too readily – we don’t have an image of the lesion at the first presentation, but we all must be critical about clinico-pathological correlation. Your biopsy should always be “as big as possible”, not “as small as possible”. 5mm ideal here. Now, we have a well-differentiated SCC. This now needs excision with a 4-5mm margin. This can be done nicely by a wedge excision (if you are experienced), and the healing is usually very good because of the great blood supply.

  15. Hi, Thanks for your comments. To answer some of your questions: He is an ex smoker, he has no palpable lymph nodes. I referred him urgently to plastics after the result as I am no experienced in doing that procedure.
    Interestingly the feedback the patient gave me was that plastics have rebiopsied the medial aspect and are considering a lymph node clearance (I only have that as hearsay from the patient).
    I don’t know exactly what it looked like when any of the other doctors saw it but the first one was at a GP led skin cancer specific clinic. Obviously I only have the patient’s recall on what other doctors advised and suggested.