Suspicious Palatal Ulcer in a Smoker Referred for Biopsy
A 58-year-old man is referred for evaluation of a 2.5 cm ulcer on the left hard palate that has been present for 6 weeks. He reports mild pain and no bleeding. He smokes one pack per day and drinks alcohol socially. He has no history of head and neck cancer. Examination shows an indurated ulcer with rolled borders and a friable base; no cervical lymphadenopathy is palpable. A recent complete blood count is normal. He asks whether he needs a biopsy or can be treated with a mouth rinse and reassessed.
1. What is your differential diagnosis, and why is biopsy indicated now?
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The differential includes squamous cell carcinoma, salivary gland malignancy (mucoepidermoid, adenoid cystic), necrotizing sialometaplasia, traumatic ulcer, major aphthous ulcer, syphilis, fungal infection, and lymphoma. The features that raise concern for malignancy are duration over 2 weeks, induration, rolled borders, and friable base in a smoker.
Biopsy is indicated now because:
- Any oral ulcer persisting beyond 2 weeks without a clear cause warrants biopsy or referral.
- Squamous cell carcinoma of the palate can mimic benign lesions.
- Early diagnosis improves outcomes.
- A trial of rinse and reassessment would delay diagnosis and is inappropriate.
An incisional biopsy including the ulcer edge and adjacent normal tissue is preferred; avoid superficial swab only. Consider imaging (CT/MRI) if malignancy is confirmed for staging.
2. How would you perform the biopsy and what specimens would you send?
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Perform an incisional biopsy at the ulcer margin, including a portion of the indurated edge and some adjacent normal tissue, because the center may be necrotic. Use local anesthesia with epinephrine for hemostasis, and avoid injecting directly into the lesion to prevent distortion. Obtain hemostasis with pressure or suture.
Send the specimen in formalin for histopathology. If infection is suspected, also send a separate swab or tissue for culture and sensitivity, and consider fungal stains. If lymphoma is suspected, send fresh tissue in saline for flow cytometry or immunohistochemistry; coordinate with pathology beforehand. Label the specimen and include clinical history.
Do not perform an excisional biopsy of a suspected malignancy before staging, because it may compromise later resection margins.
3. If the biopsy shows squamous cell carcinoma, what are the next steps in workup and referral?
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Next steps include staging and multidisciplinary referral:
- Complete head and neck examination, including flexible endoscopy if indicated.
- Imaging: contrast-enhanced CT or MRI of the neck to assess local extent and nodal disease; consider PET-CT for advanced disease.
- Refer to a head and neck multidisciplinary team (surgical oncology, radiation oncology, medical oncology).
- Assess nutritional status, dental status, and smoking/alcohol cessation counseling.
- Discuss the need for neck dissection based on nodal status and depth of invasion.
- Do not delay referral for additional biopsies if the diagnosis is confirmed.
Prognosis and treatment depend on stage, and the patient should be counseled about cessation and follow-up.