A 71‑year‑old male presents with a 6‑ to 7‑month history of a painful, enlarging left lower‑lip lesion with white patches and intermittent malodorous drainage; he is edentulous, has a prior left‑sided tongue squamous cell carcinoma treated with hemiglossectomy, congestive heart failure, atrial fibrillation on apixaban (Eliquis), digoxin, furosemide, empagliflozin (Jardiance), metoprolol, and occasional acetaminophen, and now reports ear fullness and dry itchy hand skin—what is the appropriate next step in management?

Urgent Referral for Biopsy of Suspected Recurrent Squamous Cell Carcinoma

This patient requires immediate referral to a head and neck oncology center for excisional biopsy of the lower lip lesion, as the clinical presentation—a painful, enlarging lesion with white patches in a patient with prior tongue squamous cell carcinoma—strongly suggests malignant recurrence or a new primary oral cavity cancer. 1

Clinical Red Flags Mandating Urgent Evaluation

This presentation contains multiple alarm features that demand expedited oncologic assessment:

• Non-healing ulcer with white patches persisting 6-7 months is a cardinal sign of squamous cell carcinoma and requires pathological confirmation 1
• Prior history of tongue squamous cell carcinoma places him at substantially elevated risk for second primary tumors in the oral cavity, with most recurrences occurring within the first 2-3 years 1
• Severe pain preventing eating, drinking, and sleeping suggests deep tissue invasion or perineural involvement 1
• Progressive enlargement over months is characteristic of malignant rather than benign lesions 2
• Malodorous drainage (even if improved) indicates tissue necrosis consistent with invasive carcinoma 2

Immediate Diagnostic Workup Required

The following evaluation must be completed urgently at a tertiary head and neck cancer center:

Pathological Confirmation (Mandatory)

• Excisional biopsy is both diagnostic and therapeutic for lower lip lesions and should be performed under local anesthesia 2
• For lesions confined to the vermilion, use a transverse mucosal incision at the vermilion-vestibular junction to conceal scarring 2
• If the lesion crosses the vermilion-cutaneous border, perform a vertical incision or wedge excision 2
• Pathological confirmation is mandatory before any treatment decisions 1

Staging Imaging

• Contrast-enhanced CT or MRI of the head and neck is mandatory to assess the primary tumor extent and regional lymph nodes 1
• Chest CT is essential given his smoking history and prior head and neck cancer to evaluate for distant metastases or second lung primary 1
• FDG-PET/CT should be considered if recurrence is confirmed, as it has higher sensitivity than CT alone for detecting occult disease 1

Cervical Lymph Node Assessment

• Physical examination must include thorough palpation of submandibular, submental, and cervical lymph nodes 2
• Lower lip carcinomas drain primarily to submandibular nodes, with possible contralateral spread 3
• Non-tender, firm lymph nodes are highly suspicious for metastatic disease 2

Critical Management Considerations

Anticoagulation Management

• The patient is on apixaban (Eliquis) for atrial fibrillation, which must be carefully managed peri-procedurally 1
• Coordinate with his cardiologist regarding temporary anticoagulation interruption for biopsy, balancing stroke risk against bleeding risk
• For minor procedures like incisional biopsy, apixaban can often be held for 24-48 hours; for more extensive excision, longer interruption may be needed

Cardiac Optimization

• His congestive heart failure and atrial fibrillation require pre-operative assessment before any surgical intervention 1
• Ensure he is seen by cardiology to optimize medical management (digoxin, metoprolol, furosemide) before surgery
• Document his functional status and any recent decompensation

Nutritional Status

• Severe dysphagia limiting intake to soft foods only indicates significant nutritional compromise 1
• Obtain baseline weight, albumin, and complete blood count 1
• If malignancy is confirmed and treatment planned, early nutritional support (potentially PEG tube) may be necessary 4

Treatment Algorithm Based on Biopsy Results

If Squamous Cell Carcinoma is Confirmed

For lesions >2 cm or depth >5 mm:

• Surgical excision with 8-10 mm margins is the primary treatment 3
• Ipsilateral selective neck dissection (levels I-III) should be performed concurrently if tumor depth exceeds 5 mm, as occult metastases occur in >30% of such cases 5
• Radiotherapy provides cure rates comparable to surgery and often yields superior cosmetic outcomes 2

Adjuvant therapy indications:

• Postoperative radiotherapy is recommended for surgical margins <5 mm, perineural invasion, lymphatic invasion, >1 positive node, or extracapsular extension 1
• Postoperative chemoradiotherapy is indicated for R1 resection or extracapsular rupture 1
• Treatment should begin within 6-7 weeks of surgery 1

If Actinic Cheilitis (Premalignant) is Found

• Simple excision with primary closure for localized disease 2
• CO₂ laser ablation or photodynamic therapy for extensive lesions 2

If Benign HPV-Related Lesion is Found

• Complete surgical excision is curative; recurrence is uncommon with complete removal 2

Common Pitfalls to Avoid

• Do not delay biopsy for "observation"—a 6-7 month non-healing lesion with these features requires immediate tissue diagnosis 1
• Do not perform incisional biopsy when excisional biopsy is feasible—excisional biopsy provides both diagnosis and treatment 2
• Do not ignore the neck—elective neck dissection is indicated for larger or deeper tumors even without palpable nodes 5
• Do not underestimate the impact of anticoagulation—coordinate with cardiology but do not let this delay oncologic evaluation beyond 1-2 weeks 1

Multidisciplinary Team Requirements

This patient requires coordinated care from:

• Head and neck surgical oncology (primary management) 1
• Radiation oncology (if adjuvant therapy needed) 1
• Medical oncology (if systemic therapy indicated) 1
• Cardiology (perioperative cardiac optimization)
• Registered dietitian (nutritional support) 4
• Speech-language pathology (swallowing rehabilitation) 1

Timeframe for Action

Referral to head and neck oncology should occur within 1 week, with biopsy performed within 2-3 weeks of initial presentation 1. Most recurrences and second primaries in head and neck cancer patients occur within the first 2-3 years after initial treatment, and this patient is well within that high-risk window 1.