A 60-year-old man comes to the office due to a sore on his lip. Four weeks ago, he noticed a painful lesion on his lower lip; in the past week, the lesion became ulcerated. Medical history is unremarkable. The patient does not use tobacco, alcohol, or illicit drugs. He works as a farmer and lives with his grandchildren. Vital signs are normal. Examination shows a 6- × 7-mm scaly papule with a central ulcer located in the vermilion zone of the lower lip. The oral mucosa and tongue are free of lesions. There are no palpable submental or submandibular lymph nodes, and the remainder of the physical examination is unremarkable. What is the most likely diagnosis?
Squamous cell carcinoma of skin | ||
Risk factors |
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Clinical features |
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Diagnosis |
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Treatment | Invasive SCC
| SCC in situ
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5-FU = 5-fluorouracil; C&E = curettage & electrodesiccation; SCC = squamous cell carcinoma. | ||
This patient has a persistent, ulcerated scaly papule on the lower lip, concerning for squamous cell carcinoma (SCC). SCC is the most common malignancy of the lip, with 95% of cases occurring in the lower lip vermilion, likely due to higher sunlight exposure.
SCC can affect any cutaneous surface. In fair-skinned patients, it is most common in sun-exposed areas. In dark-skinned patients, SCC typically affects non–sun-exposed surfaces and areas with chronic inflammation (eg, venous stasis ulcers) or chronic scarring (eg, burn scars). In addition, high-risk human papillomavirus infection can cause genital and periungual SCC.
Well-differentiated SCC typically presents as firm, scaly papules, plaques, or nodules with or without ulceration, ranging from 0.5-1.5 cm. Poorly differentiated SCC, in contrast, presents with beefy red papules or nodules that may bleed or ulcerate. Most SCC lesions are asymptomatic, although some are painful or pruritic. Perineural invasion can cause local paresthesia. Metastatic disease should be suspected when regional lymphadenopathy is present.
(Choice A) Aphthous ulcers (ie, canker sores) are painful, shallow, round ulcerations with white/yellow bases. They are recurrent and self-limiting and affect only the oral mucosa, not the keratinized epithelium of the lips.
(Choice B) Basal cell carcinoma classically presents as a shiny, pearly nodule with telangiectasia. Unlike SCC, it is usually not scaly.
(Choice C) Herpes labialis typically presents at the vermilion border as painful vesicles that ulcerate, becoming crusted over the next week. Lesions typically resolve within 2 weeks, not lasting a month as in this patient.
(Choice E) Verruca vulgaris (ie, common wart) is characterized as a firm papule that is hyperkeratotic and with clefted surface. It does not ulcerate.
Educational objective:
Cutaneous squamous cell carcinoma (SCC), the most common malignancy of the lower lip, can affect any cutaneous surface. Well-differentiated SCC presents as firm, scaly papules, plaques, or nodules with or without ulceration. Poorly differentiated SCC presents with beefy red papules or nodules that may bleed or ulcerate.