What is the best course of action for a 68-year-old male patient with a history of squamous cell carcinoma (SCC) of the left tonsil, presenting with a 0.6 cm painful lesion on his left upper gums, and experiencing dry mouth symptoms, given his edentulous (without teeth) status?

Urgent Biopsy Required for Suspected Recurrent Squamous Cell Carcinoma

This patient requires immediate biopsy of the gum lesion to rule out recurrent squamous cell carcinoma, given his history of tonsillar SCC and the presence of a painful, non-healing oral lesion lasting 3 weeks. 1

Immediate Diagnostic Workup

Clinical Examination and Biopsy

• Pathological confirmation is mandatory for any suspicious oral lesion, particularly in patients with prior head and neck SCC 1
• The lesion can be biopsied transorally under local anesthesia given its accessible location on the upper gums 1
• Non-healing ulcers or lesions in the mouth, especially those causing chronic pain, are red flag symptoms that warrant immediate evaluation for SCCHN 1
• A neck mass or mouth lesion combined with regional pain suggests a malignant or premalignant process 2

Imaging Studies

• Contrast-enhanced CT scan and/or MRI are mandatory to assess the primary lesion and regional lymph nodes 1
• Given his history of tonsillar SCC, chest CT should be performed to assess for distant metastases or second primary tumors, as this represents high-risk disease 1
• FDG-PET is recommended in cases of suspected recurrence in patients with prior head and neck cancer treatment 1

Critical Context: High-Risk Patient Profile

Why This Patient Is High-Risk

• History of squamous cell carcinoma of the tonsil places him at significantly elevated risk for second primary tumors or recurrence 1
• The 3-week duration of a painful, non-healing lesion is concerning for malignancy rather than benign inflammatory conditions 1
• His edentulous status and dry mouth symptoms (likely from prior radiation therapy) are consistent with post-treatment sequelae but do not explain a new painful lesion 3

Common Pitfall to Avoid

• Do not delay biopsy by empirically treating this as an aphthous ulcer, candidiasis, or radiation-related mucositis 4
• Studies demonstrate that delayed diagnosis of oral cavity carcinoma occurs when clinicians misdiagnose oral lesions as benign conditions and treat them empirically without biopsy 4
• Even experienced dermatologists have been shown to misdiagnose oral SCC as benign lesions, leading to dangerous delays 4

Additional Baseline Assessments

Laboratory and Functional Evaluation

• Complete blood count, liver enzymes, serum creatinine, albumin, coagulation parameters, and TSH should be obtained 1
• Performance status, nutritional status with weight assessment, speech and swallowing function, and psychosocial evaluation should be documented 1
• Dental/stomatological evaluation is important, though he is already edentulous 1

Management of Dry Mouth Symptoms

Symptomatic Treatment

• Pilocarpine hydrochloride tablets are FDA-approved for treatment of dry mouth from salivary gland hypofunction caused by radiotherapy for head and neck cancer 3
• The recommended dosing is 5 mg three times daily, which can be adjusted based on response and tolerability 3
• However, addressing the dry mouth is secondary to the urgent need for tissue diagnosis of the gum lesion 3

Next Steps After Biopsy

If Biopsy Confirms Recurrence or New Primary

• The patient should be discussed in a multidisciplinary tumor board to determine if salvage surgery, re-irradiation, or systemic therapy is appropriate 1
• Patients with local or locoregional recurrence should be referred to a tertiary center to consider curative treatment strategies 1

If Biopsy Shows Benign Pathology

• Alternative diagnoses such as traumatic ulceration, inflammatory conditions, or radiation-related changes can be considered 1
• Symptomatic management and close follow-up would then be appropriate 1

The key principle is that any oral lesion in a patient with prior head and neck SCC must be biopsied promptly—clinical appearance alone cannot reliably distinguish benign from malignant lesions. 1, 4