We received a number of great responses to part 1 of this case presentation in the eTalk thread on this topic, and as many of you noted, there are a number of possibilities to include in the differential diagnosis for this challenging patient.
In our care of this patient, considering the nature of the lesion, its clinical findings and the duration, a shave biopsy was performed in the office. This was sent to the BAKO pathology services, and images from the histology slides are below.
The diagnosis was superficial squamous cell carcinoma that was moderately to well differentiated. The proliferation of the carcinoma cells were noted to extend through the epidermis and into the papillary dermis, with mild to moderate nuclear pleomorphism and increased mitotic activity.
| Squamous cell carcinoma may occur in normal skin or in skin that has been injured or inflamed. Most skin cancers occur on skin that is regularly exposed to sunlight or other ultraviolet radiation. |
| The earliest form of squamous cell skin cancer is called Bowen's disease (or squamous cell in situ), and is notable because this type has not spread to nearby tissues. |
Actinic keratosis is a precancerous skin lesion that rarely may become a squamous cell cancer.
Risks for squamous cell skin cancer include:
- Having light-colored skin, blue or green eyes, or blond or red hair
- Long-term, daily sun exposure (such as in people who work outside)
- Many severe sunburns early in life
- Older age
- Having had many x-rays
- Chemical exposure
- Chronic wounds
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Symptoms
Squamous cell skin cancer usually occurs on the face, ears, neck, hands, or arm. It may occur on other areas. The main symptom is a growing skin lesion that may have a rough, scaly surface and flat reddish patches or plaques. These lesions may be friable and tend to bleed easily. The earliest form appears as a scaly, crusted, and large reddish patch (often larger than 1 inch). A wound that does not heal can be a sign of squamous cell cancer. Any change in an existing wart, mole, or other skin lesion could be a sign of skin cancer. |
Diagnostics
Biopsy is the gold standard in the diagnosis of squamous cell carcinoma, and there are a variety of sampling options to obtain the appropriate degree of tissue. In cases such as this, a shave or punch biopsy can provide a great deal of information to allow the pathologist to make the appropriate diagnosis. |
Considering these findings, and the reality that largely these lesions can be consider “cured” with complete resection, the patient was booked for excisional biopsy at the local community hospital. (Fig. 2)
Figure 2 |
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She was brought to the operating room and the skin lesion was removed in total with approximately 0.3-0.4 cm margins. The full-thickness lesion was sent for fresh frozen section, and the pathologist confirmed the diagnosis of squamous cell carcinoma, and was able to confirm that the margins were clean with no further extension of the squamous cell carcinoma into the surrounding tissues. Deep wound cultures were also obtained at this time as well to evaluate for the possibility of underlying infectious etiology –these cultures were negative.
Following the excision of her malignant skin lesion, the patient was left with a large soft tissue defect along the medial ankle. (Fig. 3)
Figure 3 |
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Considering the previous history, the patient’s comorbidities, and the above clinical findings, how would you proceed in the management of this large soft tissue defect?
Please share your thoughts and insights on the eTalk thread on this topic — we share them as well as the case conclusion for this case in an upcoming Residency Insight.
We at PRESENT love hearing from you. I would encourage you to share your experience, pearls, and wisdom on this topic, or on any other that you would like to share with our online community via eTalk.
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