Home MSK A Case of Squamous Cell Carcinoma
Clinical History
Examination
Investigations
Diagnosis
Treatment
Discussion
References
The 85-year-old lady presented with complaints of:   Swelling on Right Foot since 2 months.   The patient was normal 2 months back when she noticed swelling on the Right Foot.  
Initially swelling was 1cm x 1cm in size and has gradually progressed to the current size of 10cm x 8cm and 5cm x 4cm   
Swelling is also associated with bloody discharge, spontaneous, minimal amount of bleeding, which stops on its own.  
No h/o trauma No h/o pain on movement
No h/o skin change No h/o fever No h/o anorexia, weight loss No h/o similar swellings in other sites  
Not a k/c/o Type 2 Diabetes Mellitus, Hypertension, Asthma, Epilepsy
General Physical Examination:   The patient is moderately built and nourished, is alert, cooperative, and well oriented   No pallor, No icterus, No clubbing, No cyanosis, Right inguinal lymph node enlarged, No edema.  

Inspection: Two swellings present on the medial aspect of lower 1/3rd of the Right leg   1st swelling of size 10cm x 8cm just above the medial malleolus which is exophytic.

The surface appears irregular with ulceration & bloody discharge   Margins are well defined, the skin over the swelling is ulcerated with necrotic patches   2nd swelling is 1cm above the first swelling, 5cm x 4cm in size, the surface appears irregular, margins are well defined The skin over the swelling is stretched and shiny with minimum ulceration

No scars/sinuses   No other swellings are seen   Passive movement at the ankle is normal but aggravates bleeding   Insert Picture 1 Palpation: No local rise of temperature Tenderness + Solitary swelling, No ridge between the two masses
Other inspection findings confirmed   Swelling is variable in consistency, non-mobile bleeds on touch, the skin over swelling is not pinchable  

Examination of draining lymphatics: Solitary 1cm x 1cm lymph node, palpable in Right inguinal region Non-tender, freely mobile, and firm   CVS: S1 &S2 heard, No added murmurs.   RS: B/L NVBS, No added sounds.   P/A: Soft and non-tender with no organomegaly.   CNS: Conscious and oriented.

Hb – 9.6g/dL

ECG: Irregular missed beats

2D Echocardiography:

Aortic Valve Sclerosis with Mild Tricuspid Regurgitation with Pulmonary Artery Hypertension.

Xray of Right Leg: AP, Lateral

Serology

HIV – Negative

HbsAg – Negative

HCV – Negative

Squamous Cell Carcinoma over the medial aspect of Right foot

Wide Local Excision done under Spinal Anaesthesia

The tissue sample sent for Histopathological Examination showed high-grade sarcoma

Cutaneous squamous cell carcinoma (cSCC) is a malignant tumor arising from epidermal keratinocytes [1]

It is mainly caused by UV light exposure, which leads to widespread DNA damage and extremely high mutational loads [2]

These cancers can appear as:

•Rough or scaly red patches, which might bleed

•Raised growths or lumps

•Open sores (which may have oozing or crusted areas) that don’t heal or that heal and then come back

•Wart-like growths [3]

Squamous cell carcinoma (SCC) has a higher risk of metastasis.

In this case, the patient has inguinal lymph node enlargement indicative of metastasis.

A skin biopsy is mandatory in all patients with suspected squamous cell carcinoma. Histopathologically, squamous cell carcinoma is notable for irregular nests, cords, and sheets of neoplastic keratinocytes invading the dermis.  [4]

Here, in this case, an X-Ray was taken to check the extent of invasion of the tumor, and a wide excisional biopsy was done to confirm the diagnosis.

The major preventive measure includes the use of appropriate sun-protective clothing, the use of broad-spectrum (UVA/UVB) sunscreen with at least SPF 50, and avoidance of intense sun exposure that may prevent this cancer. [5]

Surgical excision is the only means of providing accurate information on histology and clearance. A 4 mm clearance margin should be achieved if the SCC measures <2 cm and a 1 cm clearance margin if >2cm. [6]

Other procedures include:

Mohs Surgery (During the surgery, after each removal of tissue and while the patient waits, the tissue is examined for cancer cells) [7]

 Radiation therapy is often used afterward in high-risk cancer or patient types

In the case of SCC in situ (Bowen’s disease) treatment includes photodynamic therapy with 5-aminolevulinic acid, cryotherapy, topical 5-fluorouracil or imiquimod, and excision. [8] The long-term prognosis of squamous cell carcinomas depends on: the sub-type of the carcinoma, available treatments, location(s) and severity, and various patient health-related variables (accompanying diseases, age, etc.). Generally, the long-term outcome is positive, as less than 4% of Squamous cell carcinoma cases are at risk of metastasis. [9]

[1] Waldman A, Schmults C. Cutaneous Squamous Cell Carcinoma. Hematol Oncol Clin North Am 2019; 33:1  
[2] Robbins Basic Pathology 10th ed. Elsevier 2017. 900P.g  
[3] Christensen SR, Wilson LD, Leffell DJ. Chapter 90: Cancer of the Skin. In: DeVita VT, Lawrence TS, Rosenberg SA, eds. DeVita, Hellman, and Rosenberg’s Cancer: Principles and Practice of Oncology. 11th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2019.  
[4] Kueder-Pajares T, Descalzo MA, García-Doval I, Ríos-Buceta L, Moreno-Ramírez D. Evaluation of Structure Indicators for Assessing Skin Cancer Quality of Care in Dermatology Departments. Actas Dermosifiliogr. 2018 Nov;109(9):807-812. English, Spanish. doi: 10.1016/j.ad.2018.06.004. Epub 2018 Aug 6. PMID: 30093072..
  [5] Gallagher, RP; Lee, TK; Bajdik, CD; Borugian, M (2010). “Ultraviolet radiation”. Chronic Diseases in Canada. 29 (Suppl 1): 51–68.  
[6] Bailey and Love’s, Short Practice of Surgery 27th ed, Taylor & Francis Group 2018. Pg608
  [7] Steinman HK: Mohs Surgical Techniques In: Gross KG, Steinman HK, Rapini RP. Mohs Surgery Fundamentals and Techniques. St Louis: Mosby; 1999. p.49-72.  
[8] Bath-Hextall, Fiona J; Matin, Rubeta N; Wilkinson, David; Leonardi-Bee, Jo (2013-06-24). “Interventions for cutaneous Bowen’s disease”. Cochrane Database of Systematic Reviews (6): CD007281. doi:10.1002/14651858.CD007281.pub2. ISSN 1465-1858. PMC 6464151. PMID 23794286.  
[9] Brantsch Kay D; Meisner Christoph; Schönfisch Birgitt; Trilling Birgit; Wehner-Caroli Jörg; Röcken Martin; Breuninger Helmut (2008). “Analysis of risk factors determining prognosis of cutaneous squamous-cell carcinoma: A prospective study”. The Lancet Oncology. 9 (8): 713–720. doi:10.1016/S1470-2045(08)70178-5. PMID 18617440.  

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