Multiple Masses on the Tongue of a Patient with Generalized Mucocutaneous Lesions

I n May 2007, a 62-year-old man presented with a 6-cm fungating mass on the dorsum of the tongue (Figure 1), which had lasted for an unknown period of time. The lesion had a roughened and irregular surface, with areas of white keratosis admixed with areas of necrosis. It felt indurated on palpation. Two additional smaller exophytic lesions were observed on the dorsum of the tongue: one adjacent to the main mass and the other on the apex. Both showed surface nodularity and minimal surface keratin production. The surrounding mucosa demonstrated hyperkeratosis and a pebbled surface. Interlacing white keratotic striae were observed on the right buccal mucosa (Figure 2), while the mucosa of the left cheek had an erosive area bordered by fine, white radiating striae (not shown in figure). A skin examination revealed polygonal, flat-topped papules covered with a fine network of white lines on the legs (Figure 3). Furthermore, the patient had an erosive area on his glans penis (Figure 4). The clinical appearance of the fungating mass immediately raised a high suspicion of malignancy, and a biopsy was promptly planned. For the two other exophytic lesions on the dorsum of the tongue, the differential diagnosis included squamous cell carcinoma, verrucous carcinoma, squamous papilloma, condyloma acuminatum, focal epithelial hyperplasia, and verruciform xanthoma. The differential diagnosis of the hyperkeratotic surrounding area included plaque-like lichen planus, leukoplakia (thick or verruciform), proliferative verrucous leukoplakia, and lichenoid mucositis. With regard to the buccal lesions, a clinical diagnosis of oral lichen planus (OLP) was relatively straightforward, given the presence of the bilateral interlacing white keratotic striae. Similarly, the skin lesions were highly suggestive of lichen planus, with the typical polygonal papules covered with a fine, lace-like network of white lines (so-called Wickham striae; in analogy, the interlacing white lines of reticular OLP are also referred to as Wickham striae by some authors). The erosive area on the glans penis could be erosive lichen planus, pemphigus vulgaris, mucous membrane pemphigoid, plasma cell balanitis (or Zoon balanitis), or erythroplasia of Queyrat. Progress On biopsy, the fungating mass on the dorsum of the tongue showed features of an invasive squamous cell carcinoma, while the contiguous exophytic lesion turned out to be a verrucous carcinoma; the mass on the apex of the tongue was a squamous cell carcinoma in situ. Histologic appearance of the hyperkeratotic surrounding area was consistent with OLP. Biopsies of either buccal and cutaneous …