A 64-year-old man presents for a concern about a lesion on his tongue that he noticed 4 weeks ago. He reports no pain or difficulty swallowing. Past medical history is significant for cholelithiasis and hyperlipidemia. He has a 40-pack-year smoking history and drinks 2–3 beers daily. Vital signs are within normal limits. On physical examination, a 1.5-cm, bright white, well-demarcated patch is noted on the left lateral border of the tongue. The lesion has a slightly granular surface and cannot be scraped off with a tongue depressor. There is no associated induration or palpable cervical lymphadenopathy.
Which of the following is the most appropriate next step in the management of this patient?
The correct answer is:
B) Biopsy of the lesion
The patient is presenting with oral leukoplakia, defined clinically as a white patch or plaque that cannot be characterized clinically or pathologically as any other disease and cannot be scraped off. It is a premalignant lesion, with a risk of transformation into squamous cell carcinoma (SCC) ranging from 1% to 20%. Given the patient's significant risk factors (age, smoking, and alcohol) and the nature of the lesion, a biopsy (usually an incisional or punch biopsy) is mandatory to rule out dysplasia or occult invasive SCC.
Answer choice A: Application of topical nystatin suspension, is incorrect. Topical nystatin is the treatment for oral candidiasis (thrush). Unlike leukoplakia, thrush presents as cottage cheese-like flakes that can be scraped off, typically leaving an erythematous, bleeding base.
Answer choice C: Observation and follow-up in 6 months, is incorrect. Observation and follow-up is inappropriate because leukoplakia is a precursor to cancer, so definitive diagnosis via pathology is required.
Answer choice D: Reassurance that the lesion is benign, is incorrect. Leukoplakia is a premalignant lesion with a risk of transformation to SCC, so reassurance that the lesion is benign in inappropriate.
Answer choice E: Surgical excision with 1-cm margins, is incorrect. Wide surgical excision with large margins is the treatment for confirmed invasive SCC. For a suspicious white patch, the initial step is a diagnostic biopsy rather than definitive wide resection.
Key Learning Point
Oral leukoplakia is a white, non-scrapable plaque that represents a premalignant state. The most important diagnostic step is biopsy to assess for dysplasia or carcinoma. While leukoplakia is often benign hyperkeratosis, erythroplakia (a similar red lesion) has a much higher rate of harboring malignancy (up to 90%).
