PMC8276348_01
First visit in December 2014 showing a firm ulcer with a fibrinous base.
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The ulcer had a fibrinous base and was firm, but not indurated (Figure 1).
(a) In June 2015 an increase in size of the ulcer was seen and an excision was performed. (b) & (c) Micrographs showing ulceration with fibrinous crusta and infiltrate of neutrophil granulocytes. Hematoxyline and eosin staining at x 40 (2b) and x 400 (2c).
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F0002
A new excision was performed (Figure 2a), where HPE did not show any signs of dysplasia, but revealed an ulceration with fibrinous crusta, inflammation, and extensive infiltrates of neutrophil granulocytes (Figure 2b and c).
In December 2015 the lesion had an exophytic appearance. A dental mouthguard can be seen covering the teeth of the lower jaw to protect the mucosa of the tongue.
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At that point, the lesion had developed an exophytic appearance on the lateral side of the tongue (Figure 3).
Treatment with radiofrequency ablation of the tongue performed in February 2016.
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In February 2016, treatment with radiofrequency ablation of the tongue was carried out (Figure 4).
Follow-up in April 2016: a reoccurring exophytic growth of the lesion could be observed.
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F0005
At the follow-up in April 2016, there was a recurrent exophytic growth from the lesion (Figure 5).
During 2016 and 2017, due to several recurring exophytic growths of the lesion, the patient underwent multiple excisions.
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During the period 2016 and 2017, due to several recurring exophytic growths of the lesion, the patient underwent multiple excisions (Figures 6 and 7).
(a) & (b) Micrographs showing ulceration with extruding granulation tissue on the left, and normal epithelial surface with slight lymphoplasmacytic infiltrate underneath on the right. Hematoxyline and Eosin staining at x 40 (8a) and x 400 (8b).
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F0007
During the period 2016 and 2017, due to several recurring exophytic growths of the lesion, the patient underwent multiple excisions (Figures 6 and 7).
(a) & (b) Immunostainings for IgG (9a) and IgG4 (9b) in area under retained epithelium, both at x 400. Majority of IgG-positive plasma cells shows positive staining for IgG4.
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The ulceration formed an extruding polyploid lesion with granulation tissue rich in neutrophil granulocytes and lymphoplasmacytic cells (Figure 8a and b).
FDG PET/CT showing an increased uptake on the right side of the mouth corresponding to the right side of the tongue and cheek.
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An IgG-immunostaining was performed, a method that can be unreliable and difficult to interpret due to high-background staining (Figure 9a). In our case, the IgG-immunostaining was performed on the two larger biopsies. In both samples, >= 71% of the IgG-positive plasma cells expressed IgG4 (Figure 9b), that is, an IgG4+/IgG+ ratio of >= 71%, with IgG4+ plasma cells/high-power field (HPF) being 10-50.
In September of 2018, a new, firm lesion of the right buccal mucosa could be observed.
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There was also an increased uptake on the right side of the mouth, directly corresponding to the right side of the tongue and cheek (Figure 10).
In 2019, the lesion of the tongue remains, however is painless, less firm and without colour change or obvious progression. The lesion of the right buccal mucosa remains unchanged.
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F0011
New, firm, soft tissue changes in the mucous membrane on the right side of the buccal cheek, much like the previous changes seen on the tongue, were observed (Figure 11).