Clinical Challenge: A Growth on the Scalp of an Elderly Man - MPR

Clinical Challenge: A Growth on the Scalp of an Elderly Man

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The patient is a 91-year-old man referred by his barber for assessment of a growth on his scalp. He states that he was told by a physician that it was a “basal cell” cancer 2 years ago, but he denies ever undergoing a biopsy. He is a nonsmoker and admits to many years of prolonged sun exposure. Examination reveals a 4.2cm firm nodule. Multiple actinic keratoses are noted on his face and hands. Neck lymph nodes are nonpalpable.

Histopathology revealed a squamous cell carcinoma,  which is the second most common skin malignancy occurring in white patients in the United States with an annual incidence of more than a half million cases.1 Nodal metastases are identified in 3.7% to 5.2%...

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Histopathology revealed a squamous cell carcinoma,  which is the second most common skin malignancy occurring in white patients in the United States with an annual incidence of more than a half million cases.1 Nodal metastases are identified in 3.7% to 5.2% of patients, and 1.5% to 2.1% die of this malignancy.2 Risk factors include chronic sun exposure, tobacco use, and immunosuppression. High-risk tumors include those that exceed 2cm in diameter and have ill-defined margins.3

Primary management of advanced cases is ideally achieved by Mohs surgery.1,4 Closure often entails flap reconstruction of the defect.5 Inoperable tumors are best treated with radiation therapy, which can also be used as adjuvant treatment following tumor removal.

Dr Schleicher is director of the DermDox Center for Dermatology, as well as an associate professor of medicine at Commonwealth Medical College and a clinical instructor of dermatology at Arcadia University and Kings College.

References

  1. 1. LeBoeuf NR, Schmults CD. Update on the management of high-risk squamous cell carcinoma. seminars in cutaneous medicine and surgerySemin Cutan Med Surg. 2011;30(1):26-34.
  2. 2. Thompson AK, Kelley BF, Prokop LJ, Murad MH, Baum CL. Risk factors for cutaneous squamous cell carcinoma recurrence, metastasis, and disease-specific death: a systematic review and meta-analysisJAMA Dermatol. 2016;152:419-428.
  3. 3. Miller S, Alam M, Andersen J, et al. Basal cell and squamous cell skin cancersJ Natl Compr Cancer Netw. 2010;8(8):836-864
  4. 4. Longo I. Managing high-risk squamous cell carcinoma.  Melanoma Res.  2010;20:e26-e27.
  5. 5. Stark J, Podda S, Szymanski K. Invasive squamous cell carcinoma of the scalp and calvarium: a multidisciplinary approachEplasty. 2016;6:e29.