Squamous Cell Carcinoma of the Tongue in a Crohnʼs Disease Patient

Abstract

Case: A 36 year-old woman with CD ileocolitis presents with a new left-sided tongue lesion of 4 month's duration. There was no pain and no change in taste. She was able to scrape off the lesion but it returned. The lesion would not bleed and was not enlarging. There was no other neck swelling. Her CD had required hospitalization and small bowel resection, and has been maintained on infliximab 5 mg/kg IV every 8 weeks, azathioprine (AZA) 100 mg daily and mesalamine 2.5 g/d. Her CD has been in clinical remission for >5 years. She is a lifetime non-smoker, and does not drink alcohol. On exam, there was no submandibular, cervical or supraclavicular lymphadenopathy. There was no oral thrush, the tongue appears symmetric, and on the left lateral side is a 3 mm x 7 mm flat lesion with irregular borders (image). There were no skin lesions. Biopsy revealed superficially invasive squamous cell carcinoma (SCC), keratinizing type. The AZA was discontinued; infliximab and mesalamine continued. She underwent local excision with healing by secondary intent. Pathology confirmed a non-invasive 1.3 mm cancer, and she is thought to be cured. Discussion: The differential diagnosis of a tongue lesion in an IBD patient on immune suppression includes infectious (viral or fungal), inflammatory (lichen planus or IBD-related) and neoplastic (SCC or other) lesions. Evaluation requires careful examination and early diagnosis. IBD itself does not confer an increased risk of SCC, but exposure to AZA is a known risk factor for dermatologic and other malignancies. Tobacco and alcohol are other risk factors for SCC, but are not present in this case. Human Papilloma Virus (HPV) is another risk for SCC, but HPV-related cancers are usually more posterior in the oropharynx so that seems less likely a contributor in this case. Studies of anti-TNF have found no increased risk for SCC. Management includes discontinuation of the AZA, appropriate staging and in early stage lesions (< 3 mm deep), such as this one, surgical resection without adjuvant therapy is often curative. Clinical monitoring and close follow-up is important. Conclusions: Clinicians managing IBD should be aware of the differential diagnosis of tongue lesions and in at-risk patients, perform careful examinations and refer for early tissue diagnosis.Figure: Tongue lesion before resection.