Suspicious lateral tongue lesion in a long-term smoker

Correct answer: C. Incisional biopsy including a margin of adjacent normal-appearing tissue

• A. Excisional biopsy removes the whole lesion and is appropriate for SMALL (under roughly 1 cm) lesions that are clinically benign. A 2 cm indurated lesion suspicious for carcinoma should not be excised before diagnosis — it compromises the definitive resection margins and the surgical planning.
• B. Vital staining and a three-month review both delay diagnosis. A lesion persisting beyond two weeks after removal of a local cause requires biopsy, not further observation.
• C. CORRECT. INCISIONAL biopsy is the standard for a large or clinically suspicious lesion. Take the sample from the most suspicious area, avoid frankly necrotic centres, and include the junction with adjacent normal tissue so the pathologist can assess the transition. Histopathology is the only diagnostic test that matters here.
• D. Adjunctive light-based devices are SCREENING aids, not diagnostic tests. They cannot distinguish dysplasia or carcinoma from benign keratosis or inflammation, they carry a substantial false-positive rate, and a negative result never excludes malignancy in a clinically suspicious lesion. Using one to decide against biopsy is the error the question is testing.

Note: The two-week rule: any oral ulcer or suspicious lesion that has not resolved two weeks after elimination of an identifiable local cause requires biopsy or urgent referral.

Correct answer: B. Schedule an in-person appointment and deliver the result face to face, with the referral pathway arranged

• A. Deferring entirely to the specialist abandons the duty of the clinician who ordered the biopsy. It also delays care and leaves the patient uninformed during the interval.
• B. CORRECT. Serious diagnoses are delivered IN PERSON, in a private setting, with adequate time, ideally with a support person present, and with the next step already arranged so the patient leaves with a plan rather than only with news. The structured approach taught for this is SPIKES: Setting, Perception, Invitation, Knowledge, Empathy, Strategy and summary.
• C. Any electronic messaging channel is inappropriate for a malignant diagnosis on both confidentiality and humanity grounds. Social media in particular offers no assurance the message reaches the patient rather than a family member.
• D. A telephone call gives speed but nothing else. The patient receives life-altering news alone, with no support present, no ability for the clinician to read distress and respond, and no immediate answer to the questions that follow. Telephone is acceptable for benign results, not for this.

Note: Deliver the result yourself, in person, and have the referral in hand. The patient's first question is almost always 'what happens next' — being able to answer it is part of delivering the news well.