Aggressive squamous cell carcinoma of the lip

Abstract

Squamous cell carcinoma (SCC) of the lip typically has a good prognosis when diagnosed at an early stage and treated properly. We present a 65-year-old man with a 3-month history of an ulcerative lesion of the lower lip. On physical examination, he had an ulceration of approximately 5×5 cm in the mucosa of the lower lip, extending through 50% of the lip, and multiple mandibular and neck lymph nodes. The biopsy confirmed SCC of the lip. Surgical treatment was recommended, but the patient was lost to follow-up. The patient eventually returned to the hospital for medical treatment. However, the physical examination, and the images obtained showed progression of the disease. Chemotherapy was started with improvement in the primary site, but he then developed a large submental mass compatible with SCC. The tumour was considered incurable at that time. Palliative radiation therapy was offered; however, he refused any further procedures or treatment.

Background

Skin cancer is the most common cancer in the USA and the incidence is exceeding that of all other cancers combined.¹ Squamous cell carcinoma (SCC) of the lip is a relatively common malignancy of the head and neck, accounting for approximately one-quarter of oral cavity cancers. It is generally curable compared with other malignancies of the head and neck with a 5-year survival rate of up to 82.1%. However, it has been associated with an increased risk of poor outcome with local and regional metastasis, recurrence and death.^{2 3} The age of diagnosis, the site of the lesion and the disease stage have all been considered the most important factors for survival.³

Surgical resection is currently the best method in the treatment of SCC, but it has been associated with anatomical, functional and aesthetic defects. Photodynamic therapy is a non-invasive treatment option for patients who are not eligible for surgery and radiation therapy. It is considered a palliative treatment when there is local and regional dissemination.

Our patient had a medical condition with a good survival rate. However, with the neglect of his medical condition and his failure to follow-up, his cancer progressed rapidly to an advanced stage. His SCC was considered incurable and he received palliative radiation therapy.

Case presentation

A 65-year-old Hispanic man presented to the emergency department of our institution in January 2020 because of increasing discomfort in the lower lip. He first developed a lower lip lesion 5 years ago that was biopsied and diagnosed as a bacterial infection that was then treated with antibiotics. During the last 3 months, he had a new lesion in the same area that he described as multiple vesicles that turned into an ulcer of the mucosa of the lower lip. He used home remedies by himself to take care of the ulcer. However, it continued to increase in size and discomfort and he presented to our institution. He had no significant medical history and had a family history of maternal lung cancer. He did not take any medications and had no known allergies. He denied any weight changes, fever, chills, anorexia or purulent discharge. He denied the use of tobacco and alcohol. He had not visited a dentist in the last 3 years. His cardiopulmonary examination was normal. He had an ulcerated lesion in the mucosa of left side of lower lip of approximately 5×5 cm, extending through 50% of the lip with multiple submandibular and neck lymph nodes.

A facial CT scan showed a fungating lobulated mass in the lower lip extending to the skin margin with multiple lymph nodes. A biopsy was performed and showed an invasive poorly differentiated SCC with acantholytic features. The tumour cells were positive for p40, p16 and PDL1, and negative for adipophilin, CK7 and androgen receptors. Surgical resection of the mass was initially planned, but the patient was lost to follow-up due to personal reasons.

The patient returned to the hospital 2 months later with dysphagia. He also reported facial swelling and weight loss. The physical examination revealed an extension of the ulcer to 100% of the lower lip. A facial CT scan showed an increase in size of a lobulated mass in the lower lip, extending through the base of the oral cavity with associated erosive changes along the angle of the mandible. A positron emission tomography (PET) scan showed a fungating soft tissue mass originating in the lower lip, extending into the left neck with involvement of left submandibular and parotid glands, thoracic 11 vertebral body and with prominent lymph nodes in the left side of the neck, subcarinal and paratracheal.

Treatment

Due to the extent of the lesion, the decision of chemotherapy followed by surgical resection was considered. The patient received three cycles of cisplatin and docetaxel with improvement of the primary site mass size, his appetite and increasing oral intake. However, during the chemotherapy, he developed a worsening large fungating multinodular mass with ulceration and bleeding with contact (figure 1). A follow-up PET scan showed regional progression of the disease with new lymph nodes on the right side of the neck and chest, and right intraparotid lesions.

Figure 1.

Large fungating multinodular facial mass with ulceration and bleeding at the time of admission.

Outcome and follow-up

Considering the poor response to the chemotherapy and the inability to perform a surgical resection, the patient’s medical condition was considered incurable. He was then scheduled for palliative radiation therapy. The patient refused any further procedures or treatment. A percutaneous gastrostomy tube was placed to help with feeding as needed.

Discussion

There were an estimated 63 000 new cases of head and neck cancers in the USA in 2017, accounting for about 4% of new cases.¹ The early detection and advances in cancer treatments have contributed to the increasing survival rates.⁴ There are an estimated 430 000 head and neck cancer survivors in the USA, and the number is expected to continue to rise.⁵ The SCC of the lip has a high survival rate and multiple factors have been described in the increasing survival rate, such as early detection, access to healthcare, ethnicity and programmes targeting environmental factors such as smoking and alcohol consumption. In our patient, multiple factors determined the poor prognosis such as the lack of screening, the delay in seeking medical attention and the loss to follow-up.

Learning points.

• Squamous cell carcinoma (SCC) of the lip has a high survival rate if detected in early stage.

• SCC of the lip occurs in a part of the body that is readily accessible for early detection and yearly dental evaluation can play a role in cancer screening.

• Delayed diagnosis and treatment of SCC of the lip can be associated with worsened overall survival.

• Public education about oral cancer screening plays an important role in early diagnosis and treatment.