Case discussion: How would you treat this patient? [21 February]

In this week’s case discussion, we revisit a fascinating case submitted in 2020 by Dr Alex Speight. A 39-year-old man came to Dr Speight’s 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, the doctor biopsied the lesion and then offered cryotherapy. The patient declined and did not see the doctor again. The lesion has since grown. The patient says he has since seen two doctors who did not suggest doing anything. Dr Speight found the original biopsy result:

case discussion

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

case discussion

Update

Here is the pathology result. What next?

Pathology

– Prof David Wilkinson

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27 comments on “Case discussion: How would you treat this patient? [21 February]

  1. Dear David,
    Thank you for the case.
    I would biopsy this lesion again, it looks as SCC to me.
    Then act according to the histology, wedge vs referral to plastics, etc.

  2. I would definitely biopsy this lesion with a punch 4 mm. It’s probably an invasive SCC. There is hyperkeratosis with white circles. The first biopsy was only 2 mm in diameter and 2 mm in depth; it was too small.

  3. with all that crusting and inflammation it would be difficult to get an accurate biopsy. Need history of cold sores or sunburn and smoking. I would aim to heal with an emollient antibacterial to soften scab. Unlikely if is cold sore to react to antiviral ointment as going on too long but should be considered, perhaps orally.
    Review by dermoscopy after scab healed (7-10 days) looking for AK or early SCC in situ. High risk area. If in doubt at that stage I would be tempted to try some topical efudix.

  4. It could also be a Pyogenic granuloma, developed after initial biopsy. My approach would be to get the scab off by using topical emollient with Salicylic acid in it and review in 2/52 for further Dermoscopy +/- 4mm punch Bx for proper histologic Dx; then, manage as per result

  5. A very suspicious lesion on the lower lip of a red-headed smoker likely SCC.

    Some years ago our local pathology service wrote to us and implored not to use 2mm punch biopsies as the tissue size was too small and subject to crush artifact etc. distorting the histology, minimum would be 4mm and bigger if possible.

    I note this report says “assessment not appropriate” which suggested that further biopsy was necessary at that time.

    I would do a 6mm punch in the ‘northern’ end of the lesion where superficial crusting would not impeded the test.

    If SCC then excision.

    I would be interested to know if the result is malignant, if the GP was able to remove it (wedge excision), or if it was considered necessary to on refer to plastics.

  6. Looks clinically as an SCC. Probably initially biopsy was inadequate.
    I would perform an incisional biopsy now, as lesion still growing and not healing.

  7. This is a fast growing squamous lesion. Has to be excised totally. SCC? Probably the punch biopsy was done superficially.

  8. A non healing lip ulcer is suspicious for a SCC.
    I will advised excision biopsy

    The biopsy hits report is currently unreliable in view of sinister progression

  9. Scc vs AK. Was he a smoker or lying in the sun for long time previously. Any chronic irritation as well on the area. Any bleeding. Will give emollient to ease the scab and review in a week. Arrange for my plastic surgeon excision biopsy. Would be interested to know how the case will be treated with the outcomes.

  10. irritational keratosis due to solar rays could be treated by cryotherapy. The non-healing lesion, growing, with healed margin and keratin plates plead for a keratoacanthoma now.
    I advise the colleague to do a triangular biopsy for another anatomy pathology examination. if the diagnostic is confirmed or if the lesion presents neoplastic cells, the surgeon will treat it like an SCC. He will do a w incision with 3 to 6 mm margin according to cells differentiation .

  11. A great case. Key lessons are 1) be very suspicious and worried about lesions on the lip – they are often SCC and the area is very high risk for metastasis, 2) you can do a punch biopsy 3-4mm very easily on the lip – just go into the middle of the tumour; avoid the keratin and get into the swollen, red area. Sure, lips bleed when you biopsy but bleeding always stops with pressure or a suture. With diagnosis confirmed, treatment here is a wedge excision with direct repair. It is actually quite a straightforward procedure, but control of bleeding and careful repair of the vermillion border are key.

  12. I would rebiopsy this lesion and wait for the results.
    Depending upon the biopsy( likely SCC) a referral to plastics for excision