Non-healing tongue ulcer in a betel quid chewer
A 52-year-old man is referred by his general practitioner with a sore on the left side of his tongue that has not healed for six weeks. He has chewed betel quid with tobacco for about 25 years, smokes 20 cigarettes a day, and drinks alcohol socially. He reports mild pain on eating spicy food and has lost about 4 kg unintentionally. Examination shows a 1.5 cm ulcer with raised, indurated margins on the left lateral border of the tongue, which is fixed to the underlying tissue and tender on palpation. There is a firm 1.5 cm submandibular lymph node on the left. He was given a course of amoxicillin by his GP two weeks ago with no improvement. He asks for 'stronger medicine' and is reluctant to have a biopsy because a relative told him that 'cutting the cancer lets it spread'.
1. What is your differential diagnosis, and why is this lesion suspicious?
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Differential diagnosis:
- Squamous cell carcinoma of the lateral tongue - the leading concern.
- A chronic traumatic ulcer (e.g., from a sharp tooth or denture).
- Oral lichen planus, especially erosive type.
- Infection: tuberculosis, syphilis, deep fungal infection.
- Minor aphthous ulceration (unlikely to be indurated and fixed for six weeks).
- Leukoplakia or erythroplakia with dysplasia.
Why suspicious:
- Duration over 2-3 weeks with no healing.
- Induration, fixation and raised margins - features of malignancy rather than a simple ulcer.
- High-risk site: lateral border of the tongue.
- Strong risk factors: betel quid with tobacco for 25 years, 20 cigarettes a day, alcohol.
- Unintentional weight loss and a firm submandibular node suggesting possible metastasis.
The failure of amoxicillin does not exclude malignancy; it simply shows the lesion is not a simple bacterial infection.
2. What is the next step, and what would you not do?
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Next step: urgent referral to an oral and maxillofacial surgeon or oral medicine unit for incisional biopsy of the ulcer margin, including some adjacent normal tissue and avoiding the necrotic centre. The biopsy should be accompanied by a full oral examination, neck examination and appropriate imaging as directed by the specialist.
What I would not do:
- Do not prescribe another course of antibiotics or a steroid and 'review in two weeks'.
- Do not simply observe the lesion.
- Do not perform an excisional biopsy or reassurance in primary care.
- Do not rely on brush cytology or toluidine blue as a substitute for histopathology.
Document the referral, the risk factors discussed, and safety-netting. Delay is the main avoidable harm here.
3. How do you address his fear that a biopsy spreads cancer, and what advice do you give about his habits?
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I would explain that a biopsy is a small sample taken for examination under a microscope, and that there is no evidence that it causes cancer to spread. The real risk is delay: without a tissue diagnosis, the lesion cannot be treated correctly, and the chance of cure is better when cancer is found early. A biopsy also distinguishes cancer from conditions that need completely different treatment.
Regarding habits:
- Advise stopping betel quid and tobacco completely and reducing or stopping alcohol; refer to a cessation service and explain that continued use increases the risk of recurrence and second primaries.
- Explain field change: the whole lining of the mouth has been exposed, so follow-up of the entire mouth and neck is needed.
- Offer written information, address fear and stigma, and involve a family member if he agrees.
Arrange urgent review and ensure he knows how to contact the service if the lesion bleeds or grows.