brand logo

Am Fam Physician. 2019;100(6):367-368

Author disclosure: No relevant financial affiliations.

A 51-year-old man presented with a nodule on his tongue that had been growing slowly for three years. The nodule had become painful and interfered with his speech and oral intake. He did not recall any injury or trauma to his mouth. The lesion had never bled, ruptured, or ulcerated. His medical history was significant for current tobacco use, chronic hepatitis C, and past intravenous drug use.

Physical examination revealed an 8-mm, well-circumscribed, smooth, pink, firm nodule on the dorsal aspect of the tongue (Figure 1). A punch biopsy showed squamous proliferation with papillary surface projections and virally altered cells.

Question

Based on the patient's history, physical examination, and biopsy findings, which one of the following is the most likely diagnosis?

Discussion

The answer is A: condyloma acuminatum, a highly contagious skin lesion caused by infection with human papillomavirus (HPV) type 2, 6, 11, 16, or 18.1 Although condyloma acuminatum is usually caused by low-risk HPV types, infection with the high-risk types 16 and 18 has been linked with anogenital, head, and neck cancers.2 Condyloma acuminatum typically occurs in the anogenital region but can involve the oral cavity via oral-genital contact or autoinoculation.3 Oral condyloma acuminatum is usually asymptomatic and can appear as single or multiple pedunculated, smooth, or dome-shaped papules or plaques.1 Histopathologic features include broad hyperplastic papillary projections with cells demonstrating viral changes, such as koilocytosis, parakeratosis, and increased nuclear atypia.4 Condyloma acuminatum is treated with surgical excision or cauterization.1

Irritation fibromas are caused by chronic irritation of the oral mucosa and appear along the bite line as a single smooth, dome-shaped papule.5 Because this benign change can be difficult to differentiate from malignant neoplasms, excisional biopsy is recommended.5 Histopathologic findings of irritation fibromas include a mass of fibrous tissue covered by normal squamous mucosa.4

Oral squamous papillomas are the most common benign oral neoplasms.5 They can occur anywhere in the mouth but have a predilection for the ventral surface of the tongue. They usually appear as a single exophytic growth.5 Squamous papillomas are typically related to low-risk HPV types 6 and 11.5 These lesions can appear similar to condyloma acuminatum but are usually smaller and not clustered. Histopathology shows squamous epithelium arrayed in finger-like projections with surrounding hyperkeratosis.4 Oral squamous papillomas are treated with surgical excision.5

Pyogenic granulomas are benign, vascular tumors that can occur anywhere on the skin or mucous membranes. They appear as a single rapidly growing, friable, red papule usually on the lip or gingival mucosa. They may be pedunculated or sessile.6 Histopathology demonstrates a lobular pattern of vascular proliferation with inflammation and edema.4 The cause is unknown, but trauma and irritation are possible triggers.6 Pyogenic granulomas are treated with surgical excision followed by electrodesiccation to control bleeding.6

Squamous cell carcinoma is the most common cancer of the oral cavity. Major risk factors include tobacco and alcohol use.2 Oral squamous cell carcinoma can present as thickened white or red patches, ulcerations, or papules that are usually localized to the lateral tongue.7 Shave, punch, or excisional biopsy is recommended for diagnosis. Histopathology can consist of marked squamous epithelial atypia with nests; keratin pearls; and irregular, infiltrative stromal invasion.4 Surgery is the initial treatment.7

ConditionCharacteristicsHistopathology
Condyloma acuminatumSingle or multiple; pedunculated, smooth, or dome-shaped; located on the dorsal tongue and lingual frenulumBroad hyperplastic papillary projections with cells demonstrating viral changes, such as koilocytosis, parakeratosis, and increased nuclear atypia
Irritation fibromaDome-shaped, smooth papule typically located along the bite lineMass of fibrous tissue covered by normal squamous mucosa
Oral squamous papillomaSingle exophytic growth located on the ventral tongueSquamous epithelium arrayed in finger-like projections with surrounding hyperkeratosis
Pyogenic granulomaSingle rapidly growing, friable, red papule usually on the lip or gingival mucosa; may be pedunculated or sessileLobular pattern of vascular proliferation with inflammation and edema
Squamous cell carcinomaThickened white or red patches, ulcerations, or papules that are usually localized to the lateral tongueMarked squamous epithelial atypia with nests; keratin pearls; and irregular, infiltrative stromal invasion

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Air Force Medical Department or the U.S. Air Force at large.

The editors of AFP welcome submissions for Photo Quiz. Guidelines for preparing and submitting a Photo Quiz manuscript can be found in the Authors' Guide at https://www.aafp.org/afp/photoquizinfo. To be considered for publication, submissions must meet these guidelines. E-mail submissions to afpphoto@aafp.org.

This series is coordinated by John E. Delzell Jr., MD, MSPH, associate medical editor.

A collection of Photo Quiz published in AFP is available at https://www.aafp.org/afp/photoquiz

Continue Reading


More in AFP

More in Pubmed

Copyright © 2019 by the American Academy of Family Physicians.

This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.  See permissions for copyright questions and/or permission requests.