As housestaff, we seldom have the chance to admit a patient with cancer of unknown primary. Even if a patient presents with metastatic cancer, it is frequently evident what the primary cancer is based on epidemiology and imaging. However, in this case we have the unique opportunity of describing a metastatic cancer that presented as a lip carcinoma with several possible primary sources. Our goal is to guide the reader through the thought process involved with determining the primary malignancy in patients presenting with metastatic disease.

Case Presentation

A 54-year-old female with a 30-pack-year smoking history presented to the emergency department with pain and swelling of the right lower lip. The symptoms started one month ago with mild to moderate pain, and progressed within one week to signif1cant swelling. She had developed a lip abscess two weeks prior that was incised and drained, but now presented with worsening drainage, swelling, and pain She also had fevers and a non-productive cough for one month.