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Eroded Plaque on the Lower Lip
Author(s)
Julia L. Accetta, BS
Thomas N. Helm, MD

The Diagnosis: Squamous Cell Carcinoma

The initial clinical presentation suggested a diagnosis of herpes simplex labialis. The patient reported no response to topical acyclovir, and because the plaque persisted, a biopsy was performed. Pathology demonstrated squamous cell carcinoma (SCC) that was moderately well differentiated and invasive (Figure). 

Shave biopsy revealed irregular acanthosis of the epithelium. Many keratinocytes had glassy cytoplasm and there is a brisk lymphohistiocytic inflammatory infiltrate. Perineural and vascular invasion were not identified (A)(H&E, original magnification ×4). Higher-power examination revealed keratinocytes with hyperchromatic nuclei as well as nuclear pleomorphism (B)(H&E, original magnification ×400). Multinucleated giant cells were not identified.

Approximately 38% of all oral SCCs in the United States occur on the lower lip and typically are solar-related cancers developing within the epidermis.1 Oral lesions initially may be asymptomatic and may not be of concern to the patient; however, it is important to recognize SCC early, as invasive lesions have the potential to metastasize. Some factors that increase the chance for the development of metastases include tumor size larger than 2 cm; location on the ear, lip, or other sites on the head and neck; and history of prior unsuccessful treatment.2 Any solitary ulcer, lump, wound, or lesion that will not heal and persists for more than 3 weeks should be regarded as cancer until proven otherwise. Although few oral SCCs are detected by clinicians at an early stage, diagnostic aids such as vital staining and molecular markers in tissues and saliva may be implemented.3 Toluidine blue is a simple, fast, and inexpensive technique that stains the nuclear material of malignant lesions, but not normal mucosa, and may be a worthwhile diagnostic adjunct to clinical inspection.4

Our patient presented with a lesion that clinically looked herpetic, though he reported no prodromal signs of tingling, burning, or pain before the occurrence of the lesion. Due to the persistence of the lesion and lack of response to treatment, a biopsy was indicated. The differential diagnoses include aphthous ulcers, which may occasionally extend on to the vermilion border of the lip and exhibit nondiagnostic histology.5 Bullous oral lichen planus is the least common variant of oral lichen planus, is unlikely to present as a solitary lesion, and is rarely seen on the lips. Histologically, the lesion demonstrated lichenoid inflammation.6 Solitary keratoacanthoma, though histologically similar to SCC, typically presents as a rapidly growing crateriform nodule without erosion or ulceration.7 The differential diagnoses are summarized in the Table.

The patient underwent wide excision with repair by mucosal advancement flap. He continues to be regularly seen in the clinic for monitoring of other skin cancers and is doing well. Clinicians encountering any wound or ulcer that does not show signs of healing should be wary of underlying malignancy and be prompted to perform a biopsy.

References
  1. Fehrenbach MJ. Extraoral and intraoral clinical assessment. In: Darby ML, Walsh MM, eds. Dental Hygiene: Theory and Practice. 4th ed. St Louis, MO: Elsevier; 2014:214-233.
  2. Hawrot A, Alam M, Ratner D. Squamous cell carcinoma. Curr Probl Dermatol. 2003;15:91-133.
  3. Scully C, Bagan J. Oral squamous cell carcinoma overview. Oral Oncol. 2009;45:301-308.
  4. Chhabra N, Chhabra S, Sapra N. Diagnostic modalities for squamous cell carcinoma: an extensive review of literature considering toluidine blue as a useful adjunct. J Oral Maxillofac Surg. 2015;14:188-200.
  5. Porter SR, Scully C, Pedersen A. Recurrent aphthous stomatitis. Crit Rev Oral Biol Med. 2003;9:1499-1505.
  6. Bricker SL. Oral lichen planus: a review. Semin Dermatol. 1994;13:87-90.
  7. Cabrijan L, Lipozencic´ J, Batinac T, et al. Differences between keratoacanthoma and squamous cell carcinoma using TGF-alpha. Coll Antropol. 2013;37:147-150.
  8. Douglas GD, Couch RB. A prospective study of chronic herpes simplex virus infection and recurrent herpes labialis in humans. J Immunol. 1970;104:289-295.
  9. Alam M, Ratner D. Cutaneous squamous-cell carcinoma. N Engl J Med. 2001;344:976-983.  
  10. van Tuyll van Serooskerken AM, van Marion AM, de Zwart-Storm E, et al. Lichen planus with bullous manifestation on the lip. Int J Dermatol. 2007;46(suppl 3):25-26.
  11. Messadi DV, Younai F. Apthous ulcers. Dermatol Ther. 2010;23:281-290.
  12. Ko CJ. Keratoacanthoma: facts and controversies. Clin Dermatol. 2010;28:254-261.
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Ms. Accetta is from Tulane University School of Medicine, New Orleans, Louisiana. Dr. Helm is from the Buffalo Medical Group, New York, and the Department of Dermatology, State University of New York at Buffalo.

The authors report no conflict of interest.

Correspondence: Julia L. Accetta, BS, Orchard Park Dermatology, 3045 Southwestern Blvd #104, Orchard Park, NY 14127 (jlaccetta@gmail.com).

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Author(s)
Julia L. Accetta, BS
Thomas N. Helm, MD
Author(s)
Julia L. Accetta, BS
Thomas N. Helm, MD
Author and Disclosure Information

Ms. Accetta is from Tulane University School of Medicine, New Orleans, Louisiana. Dr. Helm is from the Buffalo Medical Group, New York, and the Department of Dermatology, State University of New York at Buffalo.

The authors report no conflict of interest.

Correspondence: Julia L. Accetta, BS, Orchard Park Dermatology, 3045 Southwestern Blvd #104, Orchard Park, NY 14127 (jlaccetta@gmail.com).

Author and Disclosure Information

Ms. Accetta is from Tulane University School of Medicine, New Orleans, Louisiana. Dr. Helm is from the Buffalo Medical Group, New York, and the Department of Dermatology, State University of New York at Buffalo.

The authors report no conflict of interest.

Correspondence: Julia L. Accetta, BS, Orchard Park Dermatology, 3045 Southwestern Blvd #104, Orchard Park, NY 14127 (jlaccetta@gmail.com).

Article PDF
ct100001001_e.pdf
Article PDF
ct100001001_e.pdf

The Diagnosis: Squamous Cell Carcinoma

The initial clinical presentation suggested a diagnosis of herpes simplex labialis. The patient reported no response to topical acyclovir, and because the plaque persisted, a biopsy was performed. Pathology demonstrated squamous cell carcinoma (SCC) that was moderately well differentiated and invasive (Figure). 

Shave biopsy revealed irregular acanthosis of the epithelium. Many keratinocytes had glassy cytoplasm and there is a brisk lymphohistiocytic inflammatory infiltrate. Perineural and vascular invasion were not identified (A)(H&E, original magnification ×4). Higher-power examination revealed keratinocytes with hyperchromatic nuclei as well as nuclear pleomorphism (B)(H&E, original magnification ×400). Multinucleated giant cells were not identified.

Approximately 38% of all oral SCCs in the United States occur on the lower lip and typically are solar-related cancers developing within the epidermis.1 Oral lesions initially may be asymptomatic and may not be of concern to the patient; however, it is important to recognize SCC early, as invasive lesions have the potential to metastasize. Some factors that increase the chance for the development of metastases include tumor size larger than 2 cm; location on the ear, lip, or other sites on the head and neck; and history of prior unsuccessful treatment.2 Any solitary ulcer, lump, wound, or lesion that will not heal and persists for more than 3 weeks should be regarded as cancer until proven otherwise. Although few oral SCCs are detected by clinicians at an early stage, diagnostic aids such as vital staining and molecular markers in tissues and saliva may be implemented.3 Toluidine blue is a simple, fast, and inexpensive technique that stains the nuclear material of malignant lesions, but not normal mucosa, and may be a worthwhile diagnostic adjunct to clinical inspection.4

Our patient presented with a lesion that clinically looked herpetic, though he reported no prodromal signs of tingling, burning, or pain before the occurrence of the lesion. Due to the persistence of the lesion and lack of response to treatment, a biopsy was indicated. The differential diagnoses include aphthous ulcers, which may occasionally extend on to the vermilion border of the lip and exhibit nondiagnostic histology.5 Bullous oral lichen planus is the least common variant of oral lichen planus, is unlikely to present as a solitary lesion, and is rarely seen on the lips. Histologically, the lesion demonstrated lichenoid inflammation.6 Solitary keratoacanthoma, though histologically similar to SCC, typically presents as a rapidly growing crateriform nodule without erosion or ulceration.7 The differential diagnoses are summarized in the Table.

The patient underwent wide excision with repair by mucosal advancement flap. He continues to be regularly seen in the clinic for monitoring of other skin cancers and is doing well. Clinicians encountering any wound or ulcer that does not show signs of healing should be wary of underlying malignancy and be prompted to perform a biopsy.

The Diagnosis: Squamous Cell Carcinoma

The initial clinical presentation suggested a diagnosis of herpes simplex labialis. The patient reported no response to topical acyclovir, and because the plaque persisted, a biopsy was performed. Pathology demonstrated squamous cell carcinoma (SCC) that was moderately well differentiated and invasive (Figure). 

Shave biopsy revealed irregular acanthosis of the epithelium. Many keratinocytes had glassy cytoplasm and there is a brisk lymphohistiocytic inflammatory infiltrate. Perineural and vascular invasion were not identified (A)(H&E, original magnification ×4). Higher-power examination revealed keratinocytes with hyperchromatic nuclei as well as nuclear pleomorphism (B)(H&E, original magnification ×400). Multinucleated giant cells were not identified.

Approximately 38% of all oral SCCs in the United States occur on the lower lip and typically are solar-related cancers developing within the epidermis.1 Oral lesions initially may be asymptomatic and may not be of concern to the patient; however, it is important to recognize SCC early, as invasive lesions have the potential to metastasize. Some factors that increase the chance for the development of metastases include tumor size larger than 2 cm; location on the ear, lip, or other sites on the head and neck; and history of prior unsuccessful treatment.2 Any solitary ulcer, lump, wound, or lesion that will not heal and persists for more than 3 weeks should be regarded as cancer until proven otherwise. Although few oral SCCs are detected by clinicians at an early stage, diagnostic aids such as vital staining and molecular markers in tissues and saliva may be implemented.3 Toluidine blue is a simple, fast, and inexpensive technique that stains the nuclear material of malignant lesions, but not normal mucosa, and may be a worthwhile diagnostic adjunct to clinical inspection.4

Our patient presented with a lesion that clinically looked herpetic, though he reported no prodromal signs of tingling, burning, or pain before the occurrence of the lesion. Due to the persistence of the lesion and lack of response to treatment, a biopsy was indicated. The differential diagnoses include aphthous ulcers, which may occasionally extend on to the vermilion border of the lip and exhibit nondiagnostic histology.5 Bullous oral lichen planus is the least common variant of oral lichen planus, is unlikely to present as a solitary lesion, and is rarely seen on the lips. Histologically, the lesion demonstrated lichenoid inflammation.6 Solitary keratoacanthoma, though histologically similar to SCC, typically presents as a rapidly growing crateriform nodule without erosion or ulceration.7 The differential diagnoses are summarized in the Table.

The patient underwent wide excision with repair by mucosal advancement flap. He continues to be regularly seen in the clinic for monitoring of other skin cancers and is doing well. Clinicians encountering any wound or ulcer that does not show signs of healing should be wary of underlying malignancy and be prompted to perform a biopsy.

References
  1. Fehrenbach MJ. Extraoral and intraoral clinical assessment. In: Darby ML, Walsh MM, eds. Dental Hygiene: Theory and Practice. 4th ed. St Louis, MO: Elsevier; 2014:214-233.
  2. Hawrot A, Alam M, Ratner D. Squamous cell carcinoma. Curr Probl Dermatol. 2003;15:91-133.
  3. Scully C, Bagan J. Oral squamous cell carcinoma overview. Oral Oncol. 2009;45:301-308.
  4. Chhabra N, Chhabra S, Sapra N. Diagnostic modalities for squamous cell carcinoma: an extensive review of literature considering toluidine blue as a useful adjunct. J Oral Maxillofac Surg. 2015;14:188-200.
  5. Porter SR, Scully C, Pedersen A. Recurrent aphthous stomatitis. Crit Rev Oral Biol Med. 2003;9:1499-1505.
  6. Bricker SL. Oral lichen planus: a review. Semin Dermatol. 1994;13:87-90.
  7. Cabrijan L, Lipozencic´ J, Batinac T, et al. Differences between keratoacanthoma and squamous cell carcinoma using TGF-alpha. Coll Antropol. 2013;37:147-150.
  8. Douglas GD, Couch RB. A prospective study of chronic herpes simplex virus infection and recurrent herpes labialis in humans. J Immunol. 1970;104:289-295.
  9. Alam M, Ratner D. Cutaneous squamous-cell carcinoma. N Engl J Med. 2001;344:976-983.  
  10. van Tuyll van Serooskerken AM, van Marion AM, de Zwart-Storm E, et al. Lichen planus with bullous manifestation on the lip. Int J Dermatol. 2007;46(suppl 3):25-26.
  11. Messadi DV, Younai F. Apthous ulcers. Dermatol Ther. 2010;23:281-290.
  12. Ko CJ. Keratoacanthoma: facts and controversies. Clin Dermatol. 2010;28:254-261.
References
  1. Fehrenbach MJ. Extraoral and intraoral clinical assessment. In: Darby ML, Walsh MM, eds. Dental Hygiene: Theory and Practice. 4th ed. St Louis, MO: Elsevier; 2014:214-233.
  2. Hawrot A, Alam M, Ratner D. Squamous cell carcinoma. Curr Probl Dermatol. 2003;15:91-133.
  3. Scully C, Bagan J. Oral squamous cell carcinoma overview. Oral Oncol. 2009;45:301-308.
  4. Chhabra N, Chhabra S, Sapra N. Diagnostic modalities for squamous cell carcinoma: an extensive review of literature considering toluidine blue as a useful adjunct. J Oral Maxillofac Surg. 2015;14:188-200.
  5. Porter SR, Scully C, Pedersen A. Recurrent aphthous stomatitis. Crit Rev Oral Biol Med. 2003;9:1499-1505.
  6. Bricker SL. Oral lichen planus: a review. Semin Dermatol. 1994;13:87-90.
  7. Cabrijan L, Lipozencic´ J, Batinac T, et al. Differences between keratoacanthoma and squamous cell carcinoma using TGF-alpha. Coll Antropol. 2013;37:147-150.
  8. Douglas GD, Couch RB. A prospective study of chronic herpes simplex virus infection and recurrent herpes labialis in humans. J Immunol. 1970;104:289-295.
  9. Alam M, Ratner D. Cutaneous squamous-cell carcinoma. N Engl J Med. 2001;344:976-983.  
  10. van Tuyll van Serooskerken AM, van Marion AM, de Zwart-Storm E, et al. Lichen planus with bullous manifestation on the lip. Int J Dermatol. 2007;46(suppl 3):25-26.
  11. Messadi DV, Younai F. Apthous ulcers. Dermatol Ther. 2010;23:281-290.
  12. Ko CJ. Keratoacanthoma: facts and controversies. Clin Dermatol. 2010;28:254-261.
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Cutis - 100(1)
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MDedge Dermatology
Publications
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Topics
Nonmelanoma Skin Cancer
Dermatopathology
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Eroded Plaque on the Lower Lip
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Eroded Plaque on the Lower Lip
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An 83-year-old man presented with a new-onset 1.2-cm eroded plaque on the vermilion border of the right lower lip that reportedly developed 2 weeks prior and was increasing in size. The plaque was moist and was composed of confluent glistening papules. Medical history was notable for the presence of both basal cell and squamous cell carcinomas. 

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