Case 1:
A 46-year-old male with a history of aplastic anemia and allogeneic
hematopoietic stem cell transplantation complicated by chronic graft
versus host disease (GVHD) resulting in multiple past squamous cell
carcinomas (SCC) of the oral cavity presented with a new \souttongue
lesion. In the past he has undergone multiple resections of tongue and
buccal mucosa cancers with reconstructions, a left neck dissection, and
adjuvant radiotherapy. His course has been complicated by a difficult
airway, vocal cord paralysis, an occluded left carotid stent, and a
complex neck abscess requiring long-term antibiotic prophylaxis.
A new oral tongue lesion was first identified on routine follow-up in
January 2020. The patient was asymptomatic without pain, bleeding, or
difficulty eating. Exam demonstrated a lesion of the right lateral
tongue with thickened leukoplakia and central depression. There was mild
erythema of the mucosa but no erythroplakia. The left lateral tongue had
minimal leukoplakia similar to prior exams. There were no palpable
cervical lymph nodes or visible lesions on flexible
nasopharyngolaryngoscopy. On repeat exam a few weeks later, the patient
reported new tongue tenderness, worse on the right side. The physical
appearance of the lesion was unchanged other than mildly increased
thickness. Given worsening symptoms, the decision was made to perform an
in-office biopsy.
Biopsy of the tongue lesion revealed squamous cell carcinoma, at least
in situ, and hyperkeratotic squamous mucosa with lichenoid chronic
inflammation. Pathology noted that invasive cancer could not be excluded
based on the biopsy specimen. We therefore planned a transoral partial
glossectomy for excision of the new tongue lesion with intraoperative
assessment of margins and possible split thickness skin graft.
At this point, COVID-19 had entered our institution. Although surgery
was the ideal approach to the diagnosis and treatment, we decided to
delay intervention for the time being given his significant
immunocompromised state and the small, relatively indolent nature of a
lesion that could be monitored visually with relative ease. He is
currently home quarantined with care coordinated via telemedicine
including weekly photographic updates of the tongue lesion (Fig. 1).