23 January 2019

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Ulcerated lesion of the tongue in a young patient: a clinical case

Co-authors: M. Mandaglio, A. Senna, A. Pispero

Giovanni Lodi

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A 19-year-old young man comes to our observation for the evaluation of an ulcerated neoformation of the tongue present for at least a month.
The patient, in apparent good conditions of general health, reports to smoke 10 cigarettes a day for about 3 years, to drink alcohol occasionally and to suffer from acute asthmatic episodes associated with seasonal allergies, for which he is today in treatment with salbutamol. At the intraoral level, an ulcerated neoformation with a diameter greater than 12 mm is found, located at the anterior third of the right lingual margin (Fig. 1). At palpation the consistency is soft and the margins of the lesion do not appear hardened. The patient does not complain of any discomfort induced by the clinical maneuvers useful for the inspection. The remaining oral mucous membranes appear injured.
After obtaining the informed written consent from the patient, and after perilesional infiltration of local anesthetic with vasoconstrictor, a punch biopsy (diameter = 5 mm) is performed taking care to understand within the tissue fragment pathological is clinically harmless tissue. At the end of the procedure the suture of the incision margins is made with single stitches in 4/0 silk. The material collected, stored in formalin at 4%, is sent to fellow anatomopathologists for the analysis of the case.

The histopathological diagnosis is of infiltrating squamous cell carcinoma with spindle-cell aspects (Fig. 2-3).

Research by PCR of HPV viral markers in the tissue taken gives negative results. The patient is referred to the Maxillofacial surgery for excision of the lesion under local anesthesia. Young patients (aged <40 years) represent about 4% of the total subjects with cancer of the mouth. In these subjects it may be necessary to review the importance of "classic" risk factors (smoking and alcohol), due to the relatively short exposure and their lower frequency compared to the traditional cases; for this reason the researchers' attention turned to different factors, such as hereditary, systemic and infectious factors. 
The differential diagnosis is with ulcerative lesions of an infectious etiology (for example, a syphilitic ulcer) and a traumatic aetiology, which however are characterized by a different clinical course.
The incisional biopsy represents the gold standard among the procedures useful for the diagnosis of ulcerated mucosal lesions that do not resolve after 14 days of antiseptic therapy. Squamous cell carcinoma accounts for 90-95% of all cases of mouth cancer and predominantly affects the sixth or seventh decade of life.

For additional information: 
Dental Cadmos n° 4/17 -  https://doi.org/10.19256/d.cadmos.04.2017.04