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A Small Nodule on the Lateral Tongue

Case Challenge Number: 34

Diagnostic Information

Additional History The patient was otherwise healthy and did not recall any trauma to the area. His dentition was well restored with no evidence of sharp cusps that would irritate this site. The patient had a history of cigarette smoking, which was estimated at one pack per day for a period of 50 years. However, he had stopped smoking four years earlier. He reported a consumption of two or more alcoholic drinks per day. Clinical Findings The patient was a well-nourished Caucasian male who appeared his stated age and was in no acute distress. Extraoral examination was within normal limits with no facial asymmetry or cervical lymphadenopathy evident. Intraoral examination revealed a firm, smooth-surfaced, sessile nodule on the left posterior lateral tongue (Figure 1).

Figure 1.A small yellowish pink nodule on the left posterior lateral border of the tongue.

The lesion was yellowish pink in color and measured approximately 6 mm in diameter. Focal white surface changes were noted at the posterior aspect of the nodule. Neither pain nor discomfort was elicited upon palpation. Excisional Biopsy and Photomicrographs An excisional biopsy was performed. Microscopic examination revealed a wedge of mucosa partially covered by stratified squamous epithelium. On the mucosal surface was an irregular nodule that exhibited ulceration of the covering epithelium (Figures 2 and 3).

Case Challenge 34 - Content - Diagnostic Information - Figure 2

Figure 2. A low power photomicrograph showing a wedge of mucosa with an ulcerated surface nodule. (Hematoxylin and eosin stain)

Case Challenge 34 - Content - Diagnostic Information - Figure 3

Figure 3. A medium power photomicrograph showing partially ulcerated squamous epithelium covered by an eosinophilic fibrinopurulent membrane. The viable epithelial cells at the bottom exhibit hyperchromatism and pleomorphism. (Hematoxylin and eosin stain)

The intact areas of epithelium demonstrated dysplastic changes that included nuclear hyperchromatism, pleomorphism, dyskeratosis, and atypical mitotic figures. Cords and islands of these dysplastic cells were seen infiltrating into the lamina propria and deeper skeletal muscle (Figures 4-6).

Case Challenge 34 - Content - Diagnostic Information - Figure 4

Figure 4. In the bottom half of this medium power photomicrograph islands of dysplastic squamous epithelial cells can be seen invading into the lamina propria beneath the surface mucosal epithelium. (Hematoxylin and eosin stain)

Case Challenge 34 - Content - Diagnostic Information - Figure 5

Figure 5. High power photomicrograph showing hyperchromatic and pleomorphic squamous epithelial cells within the connective tissue. An abnormal mitosis is seen in the upper right (arrow). (Hematoxylin and eosin stain)

Case Challenge 34 - Content - Diagnostic Information - Figure 6

Figure 6. Medium power photomicrograph showing islands of hyperchromatic squamous epithelial cells infiltrating between skeletal muscle bundles in the lower right. (Hematoxylin and eosin stain)