Special Section: Short Dermatological Cases
by Michelle Huynh
UAMS MD candidate class 2021
Derm Dilemma
This 57-year-old immunocompetent man
has had a slowly enlarging, solitary, painless,
and indurated dermal nodule with an
overlying sanguineous crust on the lower
lip for four months. A biopsy was taken and the
findings are illustrated in the accompanying photomicrographs
:
What is an appropriate
intervention?
A. Oral valaciclovir as the patient is most
likely experiencing a recurrent episode
of herpes labialis.
B. None, because this lesion is an oral
mucocele and spontaneous rupture will
lead to resolution.
C. A single IM injection of Benzathine
penicillin G, as this most likely
represents a primary syphilitic chancre
of the lip.
D. Surgical excision utilizing frozen or
permanent section control because
the biopsy demonstrates invasive
squamous cell carcinoma.
E. Cryotherapy or topical fluorouracil as
the clinical and histologic findings are
consistent with actinic cheilitis.
Answer: D. The clinical and microscopic findings
of this patient are consistent with the signs,
symptoms and histologic features of invasive
squamous cell carcinoma (SCC). Both SCC and
actinic cheilitis (“pre-cancer”) tend to occur on
the lower lip, which receives more sun exposure
than the upper lip. Any persistent, enlarging,
eroded papule or nodule of the lip should arouse
suspicion. Biopsy allows for definitive diagnosis
of SCC and differentiation from mimics. SCC of
the lip tends to exhibit aggressive local invasion
and metastatic potential, like other oropharyngeal
SCC. Excision with frozen or permanent section
margin control remains the primary therapeutic
intervention.
While mucoceles also tend to occur on the
lower lip, they involve only the mucosal surface,
are transient, and appear as bluish, translucent
papules. Recidivant herpes labialis presents as
painful vesicles on an erythematous base involving
the upper or lower lip for shorter durations.
Syphilitic chancres of the upper or lower lip initially
also appear as painless papules or nodules
that then ulcerate, but unlike SCC, chancres resolve
spontaneously in a matter of weeks and exhibit
distinct histologic features. Actinic chelitis
manifests as stable, non-indurated gray-white
scaly patches that can be managed with cryotherapy,
topical fluorouracil, or other non-surgical
modalities.
Surgical excision with frozen or permanent
section margin control remains the principal
therapeutic intervention for SCC.
70 • The Journal of the Arkansas Medical Society www.ArkMed.org