A growing white, non-wipeable lesion on the lateral border of the tongue in a 72-year-old smoker. The MOST appropriate next step is:

Correct answer: D. Incisional biopsy (lesion >1cm + high-risk location + growing + risk factors)

• A. The lesion is non-wipeable (ruling out candidiasis) and growing — antifungal treatment and delay would be inappropriate.
• B. Excisional biopsy (complete removal) is appropriate for lesions <1cm that are likely benign. For a growing lesion in a high-risk location, incisional biopsy is indicated first to establish diagnosis before planning treatment.
• C. A growing lesion in a high-risk site with a 72-year-old smoker should NOT simply be observed — active biopsy is required.
• D. Correct. An incisional biopsy (representative sample) is indicated when: the lesion is >1cm, when it is in a high-risk location (lateral tongue = highest risk for oral SCC), when it has grown, and when risk factors (tobacco, alcohol) are present. Incisional biopsy samples a portion of the lesion and surrounding tissue without attempting complete removal.