What is the next step for a patient with a lesion on the upper lip and philtrum, and is a biopsy indicated?

Biopsy for Upper Lip and Philtrum Lesion

Yes, biopsy is indicated for any persistent or suspicious lesion on the upper lip and philtrum that cannot be diagnosed clinically, particularly if it has been present for more than 2 weeks or has not responded to 1-2 weeks of treatment. 1

When Biopsy is Mandatory

For oral ulceration or lesions that persist beyond 2 weeks without clear diagnosis after clinical examination, biopsy should be performed. 1 This is critical because:

• Delayed diagnosis of malignancy directly impacts mortality and treatment options 1
• The upper lip and philtrum are high-risk sites for squamous cell carcinoma with significant cosmetic and functional implications 2, 3
• Clinical appearance alone cannot reliably distinguish benign from premalignant or malignant lesions 3

Pre-Biopsy Blood Work Required

Before proceeding with biopsy, obtain the following blood tests to exclude contraindications and provide diagnostic clues 1:

• Full blood count - rules out blood system diseases such as anemia or leukemia 1
• Coagulation studies - excludes surgical contraindications 1
• Fasting blood glucose - identifies diabetes as a susceptibility factor for invasive fungal infection 1
• HIV antibody and syphilis serology - rules out infections that can cause oral ulceration 1

Biopsy Technique Considerations

The biopsy should include adequate tissue from the most representative area of the lesion, avoiding necrotic centers. 2, 3 Key technical points include:

• If multiple sites with different morphological characteristics exist, perform multiple biopsies 1
• Sample from the border between abnormal and normal tissue to capture the full pathologic process 3
• Provide the pathologist with detailed clinical information including lesion location, duration, patient age, and clinical differential diagnosis 1, 2
• Ensure adequate specimen size for proper histopathologic evaluation 2, 3

Critical Pitfall to Avoid

Never delay biopsy while pursuing empiric treatment if the diagnosis is uncertain. 1 A common error is treating presumed inflammatory lesions without tissue diagnosis, which can delay detection of malignancy by weeks or months, directly impacting survival and requiring more extensive surgery 1, 3

When Biopsy Results are Non-Diagnostic

If initial biopsy shows only "inflammatory ulcer with lymphocytic infiltration" without specific diagnostic features, consider 1:

• Sending paraffin-embedded specimens for expert pathology consultation 1
• Repeat biopsy from a different area of the lesion 1
• Additional immunohistochemical studies if hematopoietic or lymphoid neoplasm is suspected 1