Pathology · patient case question
What is the appropriate next step?
Patient case: Suspicious lateral tongue lesion in a long-term smoker
Patient: Male, 63 years old
Chief Complaint: “There is a rough patch on the side of my tongue that will not go away.”
Background: Forty pack-year smoker, daily alcohol. Present for four months, not resolving after removal of a sharp cusp.
Vital Signs: BP 142/88 mmHg · HR 80 bpm
Findings: A 2 cm indurated, mixed red-and-white lesion of the right lateral tongue with an irregular surface. Non-tender. No palpable cervical nodes.
Show answer and explanation
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.