Enlarging, Friable Oral Lesion in an Older Man

A 67-year-old man complains of a lesion on the floor of his mouth that hasenlarged over the past year. When he touches the lesion, it bleeds easily andis friable and intermittently tender. The lesion has been present for manymonths; initially, it was a painless whitish area. The patient has no other lesionsin his mouth, and he has no dysphagia, dysarthria, or other problemsthat indicate oral dysfunction.HISTORY
The patient has chronic obstructive pulmonary disease, for which he usesinhalers. He also has diabetes mellitus, which is reasonably well controlledwith a sulfonylurea and metformin. He is a former heavy smoker (2 packs perday for many years) who currently smokes about half a pack per day. He alsowas formerly a heavy drinker; he now drinks "a beer or two" daily.PHYSICAL EXAMINATION
The patient is in no acute distress, and vital signs are normal. There isa 2- to 3-cm irregular pearly mass on the floor of the mouth to the left of thetongue. The margins are heaped and nodular, and the lesion bleeds easilywhen abraded by a tongue blade. No enlarged or abnormal lymph nodes areappreciated in the cervical or axillary regions. Chest auscultation reveals a fewdiffuse expiratory wheezes. The remainder of the physical examination isunremarkable.LABORATORY AND IMAGING STUDIES
Results of a hemogram and chemistry panel are normal. A chest radiographshows hyperaeration but no nodules or infiltrates.Which of the following statements is most likely to be true for thispatient?A. Tobacco exposure played a role in the development of the tumor, butalcohol did not.B. Local/regional recurrence poses a much greater risk than distantmetastatic spread.C. If the tumor resection margins are negative, postoperative treatment--including radiotherapy and chemotherapy--is of no additional benefit.D. The natural history of the tumor has little relation to the topographicsite of the primary cancer.CORRECT ANSWER: B
This patient almost certainly has a squamous cell carcinomaof the head and neck, located on the floor of themouth. He exhibits many of the typical clinical findings ofhead and neck cancer, which is usually defined as squamouscell carcinoma that involves the oral cavity, pharynx,or larynx. These tumors are relatively common; about40,000 new cases are diagnosed each year in the UnitedStates.¹The epidemiology of head and neck cancer has beenstudied in detail,^1-3 and the most important risk factors arealcohol and tobacco. Thus, choice A is incorrect. In fact, alcoholand tobacco seem to have a synergistic relationshipwherein the presence of both factors multiplies the riskassociated with each independently. A postulated mechanismfor this synergy is the ability of alcohol to act as a solubleinterface between tobacco, which contains carcinogens,and the cell membranes of head and neck mucosae.¹All forms of tobacco, including smokeless tobacco, havebeen shown to be risk factors for these tumors.The topographic site of the primary tumor has prognosticimplications; thus, choice D is also incorrect. Areasin the mouth, pharynx, and larynx differ markedly in theirability to induce symptoms and in their lymphatic drainage.These factors probably account for the prognostic differencesrelated to anatomic location. For example, atumor of the vocal cord produces a noteworthy symptom(hoarseness) early in its development and thus very frequentlyis less advanced--in terms of size and lymphnode metastases--at its discovery. Conversely, tumorslocated in clinically silent areas, such as the base of thetongue and hypopharynx, can grow unnoticed for long periods,and when they are finally discovered, tend to havemuch more advanced TNM (tumor, node, metastasis)profiles. Histologic differentiation and depth of pathologicinvasion are other prognostic variables in head and neckcancer.Choice B is correct because it emphasizes the locallyinvasive nature of these tumors. Distant metastases developin only about a quarter of patients.⁴ Local recurrence,local complications (eg, swallowing compromise, tumorinvasion of vital structures, such as the trachea and carotidartery), and the development of new primary tumorselsewhere in the region account for the bulk of morbidityand mortality in patients with these cancers.Recent data demonstrate the clonal nature of manyhead and neck cancers. These tumors have been shownto have cytogenetic and biochemical abnormalities withsignificant prognostic value. In addition, these abnormalitiesare present elsewhere in the head and neck regionof the patient despite the normal appearance of nearby oreven distant mucosal areas.⁵ This phenomenon has beenreferred to as "field carcinogenesis."The keystone therapy in head and neck cancers remainslocal resection, although specific tumors (eg, laryngeal)are curable by radiotherapy. However, solid datademonstrate that postoperative radiotherapy and chemotherapyreduce the risk of local recurrence and increasedisease-free and overall survival.^3,4 Additional therapy isparticularly appropriate in patients at high risk for recurrenceand in those with locally advanced disease.Thus, even if this patient's tumor resection marginswere negative, if 2 or more nodes were involved, the primarytumor was pathologically large, or high-risk histology(eg, vascular or nerve invasion) was present, hewould benefit from postoperative radiotherapy and chemotherapy.⁴ Thus, choice C is likely incorrect (pending furthersurgical and pathologic evaluation).Outcome of this case. The patient underwentsurgery and was found to have a T3N0M0 squamous cellcarcinoma of the floor of the mouth. Tumor resectionmargins were negative. He underwent a course of postoperativeconcurrent radiotherapy and chemotherapy, andat 1 year he has remained free of disease.

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