What is the appropriate examination, investigation, and treatment approach for an elderly non-smoker patient presenting with a 1-month history of a mouth lump and a history of basal cell carcinoma?

Evaluation and Management of Oral Cavity Mass in Elderly Patient with Basal Cell Carcinoma History

This patient requires urgent tissue diagnosis via biopsy to exclude oral squamous cell carcinoma or other malignancy, as a 1-month persistent oral mass in an elderly patient mandates histological confirmation regardless of smoking status.

Clinical Examination Priorities

Focused Oral and Head/Neck Assessment

Examine the lesion characteristics systematically:

• Measure the exact size of the mass and document its precise location within the oral cavity 1
• Assess morphology: determine if the lesion is exophytic, infiltrating, ulcerative, or has a raised/rolled edge 1
• Palpate for depth and fixation: assess whether the mass is mobile or fixed to underlying structures (muscle, bone) 1
• Document surface characteristics: look for ulceration, hyperkeratosis, red/white patches, or areas resembling granulation tissue 1
• Assess for chronic non-healing: any oral lesion persisting >4 weeks raises malignancy concern 1

Comprehensive Lymph Node Examination

Perform systematic bilateral cervical lymph node palpation:

• Examine all nodal basins: submandibular, submental, jugular chain, supraclavicular, and preauricular regions 1, 2
• Document concerning features: nodes >1.5 cm, firm consistency, fixation to adjacent tissues, multiple/matted nodes 2, 3
• Note: even in non-smokers, oral cavity malignancies can metastasize to regional lymph nodes 1

Additional Physical Findings to Document

• Performance status and nutritional assessment with weight history 1
• Dental examination: assess for poor oral hygiene, ill-fitting dentures, or chronic irritation 1
• Functional assessment: evaluate speech and swallowing function 1
• Symptoms suggesting deep invasion: trismus, reduced tongue mobility, referred otalgia 1

Mandatory Investigations

Tissue Diagnosis (First Priority)

Obtain histological confirmation immediately:

• Incisional or punch biopsy of the oral mass is mandatory before any treatment planning 1, 4
• Ensure adequate depth: biopsy must include deep tissue to assess invasion depth and identify aggressive histologic patterns 4
• Do not delay: tissue diagnosis is the critical first step, as clinical appearance alone cannot distinguish benign from malignant lesions 1

Imaging Studies

Contrast-enhanced CT or MRI of the head and neck is mandatory:

• Order immediately to assess primary tumor extent, bone/cartilage invasion, and regional lymph nodes 1, 2
• CT with contrast provides excellent evaluation of bone involvement and lymph node assessment 1, 2
• MRI is complementary for soft tissue detail and should be discussed with a head/neck radiologist 1

Chest imaging is required:

• Chest CT to exclude distant metastases and synchronous lung primary (important even in non-smokers) 1

Laboratory Assessment

Obtain baseline blood work:

• Complete blood count, liver enzymes, serum creatinine, albumin, coagulation parameters, and TSH 1

Optional Advanced Imaging

Consider FDG-PET/CT in specific scenarios:

• If lymph nodes are clinically positive or imaging shows suspicious nodes 1
• To evaluate for distant metastases in high-risk presentations 1

Treatment Approach Framework

Multidisciplinary Tumor Board Discussion Required

All oral cavity malignancies should be discussed by a head/neck cancer team including surgical oncology, radiation oncology, medical oncology, pathology, and radiology before definitive treatment 1

Treatment Selection Based on Diagnosis

If squamous cell carcinoma is confirmed:

• Early stage (T1-T2, N0): surgical excision with adequate margins is first-line treatment 1
• Locally advanced disease: combined modality therapy (surgery + radiation or chemoradiation) 1
• Sentinel lymph node biopsy may be considered for clinically node-negative disease depending on tumor characteristics 1

If basal cell carcinoma is found (unlikely in oral cavity):

• Surgical excision remains first-line treatment 5, 6, 7
• Mohs micrographic surgery for high-risk features or critical anatomical sites 5, 6

Dental Evaluation Before Treatment

Stomatological assessment is mandatory:

• Tooth extraction when required must be completed before radiotherapy to prevent osteoradionecrosis 1
• Coordinate with dentistry early in the treatment planning process 1

Critical Pitfalls to Avoid

Do not assume benign disease based on non-smoking status:

• Oral cavity malignancies occur in non-smokers, particularly in elderly patients 1
• HPV-associated oropharyngeal cancers can occur without traditional risk factors 2

Do not delay biopsy for imaging:

• While imaging is important, tissue diagnosis should not be delayed 1
• Both can often be obtained simultaneously

Do not perform empiric treatment without histological confirmation:

• Clinical appearance cannot reliably distinguish malignant from benign lesions 1
• Treatment planning depends entirely on accurate histological diagnosis 1

Do not overlook the patient's basal cell carcinoma history:

• While oral BCC is rare, this patient has demonstrated capacity for malignancy 8, 6
• Consider second primary malignancy risk in cancer survivors 1