Neck ultrasonography revealed a large, full-thickness, solid, hypoechoic, and hyper vascular ulcerating mass arising from the lower lip, measuring approximately 41 × 21 × 19 mm. The lesion showed irregular margins and sonographic features of tissue invasion, raising strong suspicion for an aggressive malignancy. Multiple bilateral lymph nodes were visualized, predominantly on the left side. These included a 16 × 14 mm lymph node in the left submandibular region, a 10 × 6 mm node in the submental group, and a 5 × 3 mm node in the left parotid group. The lymph nodes were solid, heterogeneously hypoechoic, and demonstrated features consistent with pathological involvement.

A contrast-enhanced CT scan of the chest, abdomen, and pelvis was performed to evaluate for possible distant metastases. The scan showed mild bilateral centrilobular emphysematous changes and linear fibrotic nodules at the apical segments of both upper lobes, suggesting chronic pulmonary changes likely secondary to smoking. However, there were no suspicious pulmonary nodules, no pathological mediastinal or hilar lymphadenopathy, and no signs of metastatic disease. The abdominal and pelvic organs, including the liver, kidneys, pancreas, spleen, gastrointestinal tract, and adrenal glands, were all unremarkable. There was no evidence of lymphadenopathy or mass lesions in the retroperitoneal or pelvic regions. Bone windows revealed diffusely decreased bone density but no obvious lesions suggestive of metastasis. Overall, no evidence of distant metastasis was found.

Fine-needle aspiration cytology (FNAC) was performed on a left group I cervical lymph node. Cytologic analysis revealed benign lymphoid cells with no evidence of malignancy. Routine blood investigations were largely unremarkable, with serum creatinine at 0.778 mg/dL and blood urea slightly elevated at 46.0 mg/dL. Fasting glucose was mildly elevated at 116 mg/dL, which may warrant follow-up but did not affect immediate surgical planning. Viral screening for hepatitis B, hepatitis C, and HIV was negative.

Postoperative Management and Follow-Up Plan:
Given the tumor’s size, depth of invasion, and the presence of lymphovascular invasion—despite clear margins and absence of nodal involvement—the patient is considered at intermediate to high risk for recurrence. A multidisciplinary tumor board evaluation is recommended to determine the need for postoperative radiotherapy to reduce local recurrence risk. Smoking cessation counseling is a critical component of his postoperative care plan due to the significant contribution of tobacco use to recurrence and secondary malignancy risk. Surveillance will include regular physical examinations, neck imaging (preferably ultrasound or MRI), and periodic chest imaging, particularly in light of his underlying pulmonary changes and smoking history. Long-term follow-up will focus on early detection of local recurrence, nodal spread, or distant metastases.