An 80 year-old woman presented with a hyper- keratotic plaque on her lower lip (Fig, 1A). The lesion had appeared several years before and had slowly increased in size. The patient had suffered from slight pain and the occasional bleeding.

The lesion was a well-demarcated, 4 x 1.5 cm sized, irregular-shaped, brown, hyperkeratotic, hard- surfaced plaque. No abnormalities were found besides the solitary skin lesion upon general physical examination. Furthermore, no palpable lymph node enlargement was perceived. Previously she was healthy. There was no remarkable medical history in her family. Routine laboratory studies including CBC, LFT, a renal function test and urinalysis were all within normal limits.

fig1. hyperkeratotic

Fig. 1. Hyperkeratotic plaque on the lower lip at the first visit (A) and after the removal of the crust (B). A punch biopsy was performed on the middle area of her lower Hp (arrow).
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fig2. the clusters

Fig. 2. The clusters of atypical squamous cells impos­ing in the dermis (А, В: H&E, x )0).

At first, actinic cheilitis and cutaneous squamous cell carcinoma were suspected, and therefore a punch biopsy was performed on the middle area of her lower lip. The histopathologic diagnosis was well-differentiated squamous cell carcinoma, which showed nests of atypical squamous cells imposing on the dermis (Fig. 2). Radical removal was considered as the first line therapy. However, the resultant defect after removal of the tumor would be more than two thirds of the lip length. The defect would then have to be repaired with orbicularis oris flaps or depressor anguli oris flaps. Even after this surgical treatment, the expected cosmetic outcome was poor, the degree of this dependant on the surgeon skill. The patient was extremely concerned about morbidity after the operation, so she refused surgical treatment. Hence we explored other treatment options.
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fig3. size-reduced

Fig. 3. Size-reduced lesion on the lower lip after 6 months of topical imiquimod therapy.

We started with topical therapy using imiquimod 5% cream on the skin lesion as previous reports and studies had shown the effectiveness of topical imiquimod for skin cancer. For efficient absorption of the cream, we first detached the crusts of the lesion (Fig. 1B). The imiquimod cream was applied five times a week. During the treatment, the patient complained of irritation to the application site, but this was tolerable so the treatment was continued for 6 months. After 6 months, the lesion size was greatly reduced to 2 x 1.5 cm, and was smaller than one third of the lip length. The remnant tumor was removed by wedge resection and repaired by primary closure without flaps and this was performed successfully (Fig. 3). The depth of tumor cell invasion was 0.6cm in the excised tumor mass and resection margins were histopathologically clear (Fig. 4). The tumor was excised completely and the lower lip where the lesion had been located was left functionally and cosmetically acceptable (Fig. 5). Up to 10 months after the operation, no sign of recurrence was seen at the treatment site. The patient also found no discomfort when speaking or eating. Viagra Super Active

fig4. the histopathology

Fig. 4. The histopathology of the free resection margins after tumor excision. (A: deep resection margin, H&E, x 100. В, C: lateral resection margin, H & E, x )0)

fig5. well-healed

Fig. 5. Well-healed lip 2 months after surgical removal of the tumor.