A non-healing tongue ulcer in a tobacco chewer
A 57-year-old farmer from a rural district near Battambang presents with a painless sore on the left side of his tongue present for 3 months. He has chewed tobacco mixed with slaked lime for about 30 years and smokes roughly 15 hand-rolled cigarettes a day. Examination shows a 2.5 × 1.8 cm ulcerated, indurated lesion on the left lateral border of the tongue, fixed to the underlying tissue, with a raised everted margin and a granular base. There is a firm, non-tender 1.5 cm left submandibular lymph node. He has no fever and no weight loss. A health centre treated him with amoxicillin 500 mg three times daily for one week with no improvement. Most lower teeth are missing; the upper left first molar has a sharp broken cusp that contacts the tongue near the lesion. No biopsy has been taken. The facility has no CT scanner but has fine-needle aspiration and a panoramic radiograph; the nearest radiotherapy centre is in Phnom Penh.
1. Give your differential diagnosis, identify the most likely diagnosis and justify it from the findings, and explain how much weight the sharp upper molar should carry.
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Most likely diagnosis: squamous cell carcinoma of the left lateral border of the tongue, with a clinically involved left level IB node.
Reasoning for that ranking:
- Site and morphology. The lateral tongue is the commonest intraoral site. An ulcer with a raised, everted margin and granular base that is indurated and fixed to deeper tissue is the classic description, and fixity means invasion beyond the mucosa.
- Chronicity. Three months without healing and no response to a week of amoxicillin makes a purely infective ulcer (traumatic, tuberculous, syphilitic, fungal) much less likely.
- Risk factors. Thirty years of chewing tobacco with slaked lime, plus 15 hand-rolled cigarettes daily. The lime raises pH and increases mucosal exposure to carcinogens; smokeless tobacco is a major oral cancer risk in this region.
- The node. A firm 1.5 cm submandibular node lies in the drainage pathway of the tongue and supports regional metastasis rather than a reactive node.
Keep on the list but lower: chronic traumatic ulcer from the sharp 26, chronic hyperplastic candidosis, erosive lichen planus, syphilitic gumma, tuberculosis, lymphoma. None explains induration with a fixed raised margin plus a hard node.
The sharp cusp is a trap. It could cause a traumatic ulcer and may be a co-factor, but smoothing it and reviewing in two weeks is not acceptable when a 2.5 cm indurated, fixed lesion with a hard node has been present for three months. Smooth it if you wish, but biopsy on the same visit; "review in two weeks" is not a diagnosis.
2. What is the appropriate next diagnostic step? Describe the biopsy you would take, the handling, and what you would deliberately not do.
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Next step: urgent incisional biopsy of the lesion plus fine-needle aspiration of the node, arranged now, not after a further review.
How to take it:
- Site: an ellipse at the periphery of the ulcer, including a rim of clinically normal mucosa and some underlying tissue. The centre is necrotic and yields non-diagnostic slough.
- Size and depth: about 1 × 0.5 cm, deep enough to include epithelium and superficial muscle; superficial shaves under-diagnose invasion.
- Avoid: electrocautery or laser on the specimen (crush and thermal artefact); excisional biopsy or "lumpectomy" of a 2.5 cm lesion you cannot clear; injecting local anaesthetic directly into the tumour margin in a way that distorts it - infiltrate away from the biopsy site.
- Handling: 10% formalin, orient on a card or with a suture, label with name, site and "left tongue margin", and send with a clinical summary including the tobacco and lime history.
- Node: fine-needle aspiration of the 1.5 cm node. Positive squamous cells support metastasis; a negative aspirate does not exclude it.
What not to do: another course of antibiotics, watchful waiting, or extracting the sharp tooth and stopping there. Do not send him away without a definite review date and a named person responsible for chasing the histology - in this setting, loss to follow-up is the commonest reason a curable cancer becomes incurable.
3. Outline your staging and referral plan, and state what you would tell the patient and why the sharp tooth is not the answer.
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Plan. (1) Incisional biopsy and node FNA as described. (2) Panoramic radiograph as a baseline for bone invasion, though the lesion is not clinically fixed to the mandible. (3) Chest radiograph, full blood count and liver function. (4) Refer to the national oncology and radiotherapy service in Phnom Penh in the same week as the biopsy, not after the result - an appointment slot takes longer to obtain than a histology report. (5) State explicitly in the referral that CT of the neck and chest is unavailable locally and must be arranged at the receiving centre for staging.
Why the sharp tooth is not the plan. Smoothing the 26 may improve comfort and remove a possible co-factor, but it will not alter a fixed, indurated lesion with a hard node. If that is all you do, you will have spent two to four weeks and the patient may return with a larger primary and bilateral nodes.
What to tell him, in Khmer, with a family member present: the sore has been there too long and looks like a growth that needs a small piece taken and tested; it is not proven yet; if it is cancer, the earlier it is treated the better the chance; chewing tobacco and lime and smoking should stop now because they worsen healing and recurrence. Give him a written appointment, a phone number, and ask about transport and money - a farmer travelling to the capital may not return unless those barriers are addressed at this visit.