Case Study: A 58-year-old male presented to a dental office for a routine checkup. Examination revealed a nonhealing ulceration of the lower lip.
Joen Iannucci Haring, DDS, MS
History
When questioned about the area, the patient claimed the ulcer had been present for at least six months, maybe longer. No pain or discomfort was noted by the patient. When questioned about excessive sun exposure, the patient stated that he spends many hours outdoors and does not use sunblock. The patient denied a history of smoking and alcohol use. No history of trauma to the area was noted.
The patient had a previous history of regular and routine dental care. At the time of the dental appointment, the patient was not taking medications of any kind. No significant problems were noted during the health history.
Examinations
Physical examination of the head and neck region revealed no abnormal findings. The patient`s vital signs were all found to be within normal limits. No palpable lymph nodes were detected. No other abnormal extraoral findings were noted. Oral examination revealed an ulcerative lesion of the vermilion of the lower lip, measuring one centimeter in diameter (see photo). When palpated, the periphery of the lesion felt indurated.
Clinical diagnosis
Based on the clinical information presented, which one of the following is the most likely diagnosis?
* erosive lichen planus
* actinic cheilitis
* squamous cell carcinoma
* traumatic ulcer
* recurrent herpes labialis
Diagnosis
squamous cell carcinoma
Discussion
Squamous cell carcinoma (SCC) is derived from the squamous epithelial cells, which are the flat and scaly cells found on the surface of the oral mucosa. When these squamous cells become cancerous, the cancer is referred to as a carcinoma, which is defined as a malignancy of epithelial origin. SCC is found both on the lips and inside the oral cavity. An estimated 90-95 percent of all oral cancers are squamous cell carcinoma. SCC behaves differently depending upon its location; therefore, a separate discussion of SCC of the lip and intraoral SCC is warranted.
The major causative factor for SCC of the lip is prolonged sun exposure. In addition, certain forms of tobacco use play a contributing role - pipe and cigar smoking are often linked to SCC of the lip.
Clinical features
Although SCC of the lip may occur at any age, this lesion most often occurs in adults between the ages of 50 and 70; men are twice as likely to be affected as women. The lower lip is affected by SCC far more frequently than the upper lip.
SCC of the lip has a variety of clinical appearances. The usual presentation is that of a nonhealing ulceration and crust. Raised and indurated borders may be present. The size is variable; a larger lesion may appear as a crater-like defect. SCC of the lip is typically not painful and very slow to metastasize (spread) to the regional lymph nodes or other organs.
Diagnosis
If a lip lesion is suspected to represent SCC, the patient must be promptly referred to an oral surgeon for biopsy. A biopsy and histologic examination is necessary to establish a definitive diagnosis of SCC.
Staging
Staging is the process of determining if and how far a cancer has spread. Both treatment and prognosis are dependent upon the stage of a cancer. Staging information is obtained from the physical exam, endoscopy, and imaging studies (CT scan, MRI, chest X-ray, or nuclear medicine scans).
The most common system used to stage oral SCC is termed the TNM System. This system describes three pieces of information: T refers to the size of the primary tumor, N describes the extent of spread to regional lymph nodes, and M indicates whether the cancer has metastasized (spread) to other organs.
Treatment
Once a diagnosis and staging has been determined, treatment can be rendered. Treatment options for SCC of the lip include surgical excision and radiation therapy. Smaller lesions may be surgically removed or irradiated, while larger lesions may require a combination of both surgery and radiation.
Moh`s micrographic surgery may be used to remove some lip lesions. This method removes the tumor in thin slices. Each slice is then immediately examined under the microscope to look for cancer cells. The surgeon continues to remove slices until the cancer is completely removed. This method minimizes the amount of normal tissue that is removed along with the tumor.
Prognosis
Treatment success is based on the size of the lesion and metastasis. SCC of the lip is slow to metastasize to regional lymph nodes and other organs. Consequently, the overall prognosis for SCC of the lip without such metastasis is favorable, with an 85 percent five-year survival rate.
Follow-up
Upon completion of treatment, a patient with SCC of the lip should receive frequent follow-up physical and oral examinations; approximately 80-90 percent of recurrent lesions appear within the first two post-treatment years. Patients are usually examined every other month during the first year, four times during the second year, and then once a year thereafter.
Oral cancer and the dental professional
Both the dentist and the dental hygienist can play an important role in the detection of oral cancer by performing a cancer screening examination. It is important to remember that early detection is critical; the earlier a lesion is diagnosed and treated, the better the prognosis.
The cancer-screening examination
A cancer-screening examination is a standardized exam for the detection of oral cancer that is recommended by the World Health Organization (WHO), the Centers for Disease Control and Prevention (CDC), and the National Institutes of Health (NIH).
A color poster illustrating each step of this cancer screening is available (at no charge) from the NIH. Detecting Oral Cancer: A Guide for Health Care Professionals can be obtained by contacting the National Oral Health Information Clearinghouse, 1 NOHIC Way, Bethesda, MD 20892-3500.
Additional resources
For additional information concerning oral cancer, the following resources are recommended:
Y American Cancer Society, (800) ACS-2345, www.
cancer.org
Y National Cancer Institute, (800) 4-CANCER, www.
nci.nih.gov
Y National Oral Health Information Clearinghouse,
(301) 402-7364, www.aerie.com/nohicweb
Cancer-screening steps
A thorough cancer screening must include the following steps:
> A review of the medical history. Question the patient concerning any changes in overall health since the last dental visit.
> An examination of extraoral structures. Examine and palpate the head and neck region for any enlarged and nontender lymph nodes.
> An examination of oral soft tissues. Examine all intraoral tissues at every visit with special emphasis on the three most common locations for oral cancer: lower lip, tongue, and floor of the mouth. If any suspicious lesion is noted, proceed with the following steps ...
> Careful questioning of the patient. Question the patient concerning the lesion: duration; changes in size, color, texture, or consistency; signs; symptoms; and history of injury to the area.
> Identification of risk factors. Question the patient to determine if there is a history of tobacco use, alcohol use, or excessive sun exposure (lip lesions).
> Identification of sources of irritation. Examine the adjacent areas for potential sources of irritation. Eliminate any sources of irritation (repair any chipped teeth or broken dentures).
> A follow-up evaluation of the lesion. If the patient is uncertain about how long the lesion has been present, instruct the patient to return for follow-up evaluation of the lesion in 10-14 days.
> Careful documentation of findings. Make certain to document the following: (l) any changes in medical history; (2) appearance, location and size of lesion; (3) duration of lesion; (4) any history of changes associated with the lesion; (5) any history of injury, signs, or symptoms associated with the lesion; (6) any risk factors or sources of irritation; and (7) any instructions to the patient concerning re-evaluation of the lesion.
> Recognition of the need for a biopsy. Recognize the need for further evaluation of any lesion that lasts longer than 14 days. The biopsy of a persistent lesion can be ordered by a dentist or a physician. If the result of the biopsy is negative and a strong clinical suspicion for oral cancer exists, the lesion should be re-biopsied.
Joen Iannucci Haring, DDS, MS, is an associate professor of clinical dentistry, Section of Primary Care, The Ohio State University College of Dentistry.
