Neglected Under Lip Cancer.

The lip represents an anatomical area of the interface between the skin and oral mucosa. It is, therefore, not entirely surprising that SCC of the lip exhibits mixed features between cutaneous and oral mucosal SCC, namely regarding risk factors and biological behaviour. The main risk factors for lip SCC include ultraviolet radiation exposure, low phototype, tobacco and alcohol use, and immunosuppression. Lip SCC usually presents clinically as a nodule or a tumour with a keratotic surface that commonly ulcerates. There is often a background of actinic cheilitis. The particularly exuberant presentation of our case can most probably be explained by the long evolution of a tumour before the patient reached medical attention. Patients with regional lymph node metastasis are usually offered regional lymph node dissection (usually of the neck). Radiotherapy and/or chemotherapy may be used in advanced cases, particularly in unresectable tumours, tumours with high-risk features and metastatic disease. The large size of a tumour in our case, most probably due to its long evolution, highlights the importance of timely diagnosis to avoid such extreme presentations and the consequent need for more aggressive treatment.

Introduction

The lip represents an anatomical area of the interface between the skin and oral mucosa [1]. It is, therefore, not entirely surprising that SCC of the lip exhibits mixed features between cutaneous and oral mucosal SCC, namely regarding risk factors and biological behaviour [1]. The main risk factors for lip SCC include ultraviolet radiation exposure, low phototype, tobacco and alcohol use, and immunosuppression [1]. Poor oral hygiene and dental status are also very frequent findings in patients with this neoplasm [2]. Recently, it was found that use of photosensitive drugs, particularly hydrochlorothiazide, may significantly increase the relative risk of lip SCC [3].

Case Presentation

A 94-year-old female was presented to the dermatology department with a large ulcerated tumour of the lower lip that was evolving for seven years. The patient lived in a rural area in Bulgaria and had a history of significant chronic sun exposure. Clinical examination disclosed a large tumoural mass occupying virtually the whole extension of the vermillion of the lower lip and extending to the surrounding perioral skin (Figs. 1a, 1b, 1c, 1d). The lesion was markedly exophytic with an ulcerated friable surface covered with black haemorrhagic crusts (Figures 1a to 1c). Oral cavity examination revealed poor oral hygiene and dental status (Figure 1d). Incisional biopsy was consistent with squamous cell carcinoma (SCC). The patient is currently scheduled for surgical treatment.

Figure 1

(1a-1d) A tumoural mass occupying virtually the whole extension of the vermillion of the lower lip and extending to the surrounding perioral skin. The surface of a tumour is covered with black haemorrhagic crusts (Figures 1a to 1c). Poor oral hygiene and dental status (Figure 1d)

Discussion

First-line treatment of lip SCC is surgical excision, whenever possible [4]. Patients with regional lymph node metastasis are usually offered regional lymph node dissection (usually of the neck) [4]. Radiotherapy and/or chemotherapy may be used in advanced cases, particularly in unresectable tumours, tumours with high-risk features and metastatic disease [4].

Regarding prognosis, lip SCC displays intermediate behaviour between cutaneous SCC and SCC of the oral mucosa, with an overall 5 - year survival rate of 82,1% [5]. The risk of nodal metastasis varies widely with primary tumour staging (e.g. T1 tumours have the nodal disease in 3, 4 to 7% of cases, whereas in T4 tumours this percentage may vary from 17 to 100%, depending on the studies). Lip SCC is thus considered a high-risk category within the group of cutaneous SCC [1][2][5]. Additional prognostic factors include the degree of differentiation of a tumour, depth of invasion and perineural invasion [1][2][3][4][5][6]. In a recent study, elderly (over 80 years-old) and non-white patients were found to have a poorer prognosis [6].

The large size of a tumour in our case, most probably due to its long evolution, highlights the importance of timely diagnosis to avoid such extreme presentations and the consequent need for more aggressive treatment (Figs.1a-1d).