Endgames Case Report

Multiple enlarging nodules on the lower limb

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e7409 (Published 15 November 2012) Cite this as: BMJ 2012;345:e7409
  1. Jack Andrews, foundation year 2 doctor,
  2. Isabel Teo, specialist registrar
  1. 1Plastic Surgery Unit, Ninewells Hospital, Dundee DD1 9SY, UK
  1. Correspondence to: J Andrews jackandrews88{at}gmail.com

A 99 year old white woman presented with a 12 month history of nodules and plaques on her left shin. They had been slowly increasing in size and bled intermittently. She denied any history of trauma to her leg and had been systemically well. She reported having high blood pressure and that she had previously had “skin problems” affecting her lower left leg that required surgery. Her only regular drug was bendroflumethiazide, and she had no known drug allergies. She was a non-smoker and drank minimal alcohol. She lived in a ground floor flat and used a walking stick. On review of her medical notes, it was discovered that two areas of squamous cell carcinoma were excised from her left shin 10 years earlier.

On examination, she was fair skinned (Fitzpatrick skin type II). There were several distinct, shiny, well circumscribed nodules on her left shin with surrounding hyperkeratotic plaques. These lesions were tender on palpation.

Questions

  • 1 What is the most likely diagnosis?

  • 2 What other examination is necessary at this consultation?

  • 3 What investigations should be considered?

  • 4 How might this condition be managed?

Answers

1 What is the most likely diagnosis?

Short answer

Squamous cell carcinoma (SCC). Given her history of SCC, these lesions are highly suspicious of a recurrence.

Long answer

In a patient with a history of slow growing nodules (figure) at a site where SCC had previously been excised, SCC is the most likely diagnosis. SCC is a malignant tumour that arises from the keratinising cells of the epidermis. It is locally invasive and has metastatic potential. The density of these lesions is highest on the face and neck, although lesions are more common on the extremities (arms, backs of hands, and lower limbs).1 SCC is more common in people over the age of 50 years, with a slight male predominance. The annual incidence of SCC in England is 23 in 100 000 people2 and the main risk factor for development is sun exposure.3 Other risk factors include fair skin, SCC in situ (intraepithelial neoplasia), human papillomavirus infection, immunosuppression, chronic ulceration, albinism, and xeroderma pigmentosum. It is usually caused by a mutation of the P53 tumour suppressor gene that leads to unregulated cell division.

Figure1

Clinical photograph showing a nodule (A), hyperkeratotic plaque (B), and ulcer (C)

Common clinical features of SCC include tender ulcers with hyperkeratosis and bleeding. Neoplastic differential diagnoses include SCC in situ, amelanotic nodular melanoma, and basal cell carcinoma. However, these differential diagnoses are unlikely in this patient given the history of SCC and the appearance of the lesions. Non-neoplastic differential diagnoses include arterial or venous ulcers, systemic vasculitis, and pyoderma gangrenosum. Salient points in the history and examination will help pinpoint the diagnosis. In particular, peripheral vascular disease could compound the presenting problem and it is important to look for this disease.

2 What other examination is necessary at this consultation?

Short answer

Examination of the draining lymph node basins (popliteal and inguinal lymph nodes in this patient) is essential to identify possible lymph node involvement. A full skin examination should also be performed to exclude concurrent skin cancers.

Long answer

SCCs are locally invasive and commonly spread along the nerves. Lesions from the lip and ears have a much higher metastatic potential than those from the lower limbs. However, fewer than 5-10% of SCCs metastasise and fewer than 1% of sun exposure induced SCCs have lymph node involvement.5 Nonetheless, it is important to examine the lymph node basins to identify possible lymphatic spread. Given that this patient’s disease was located on her left lower leg, the regional lymphatic drainage would be to the left popliteal and the left inguinal lymph nodes.

Because this patient was fair skinned (Fitzpatrick type II) and had a history of SCC, she is at risk of developing other types of skin cancer, particularly in sun exposed areas. The Fitzpatrick scale (table) classifies a person’s skin type and their tolerance of sunlight. It is used by clinicians to estimate the likelihood of a patient developing skin cancer; the fairer the skin the higher the risk. It is important to perform a full skin examination to exclude concurrent skin cancers, such as basal cell carcinomas and malignant melanomas.

Table 1

Fitzpatrick skin types4

View this table:

3 What investigations should be considered?

Short answer

A histological diagnosis is of paramount importance, so a punch biopsy or incisional biopsy of the lesion is the first line investigation. Palpable lymph nodes can also be biopsied, and staging computed tomography should be organised if there is evidence of other systemic spread, such as lymphadenopathy or weight loss.

Long answer

A punch or incisional biopsy of the lesion is the first line investigation. The tumour is graded on the basis of its histological features.6 If there is any clinical evidence of metastatic spread—such as lymphadenopathy, weight loss, or altered bowel habit—imaging should be considered. This would normally be a computed tomography staging scan. There are four clinical stages (I-IV), which can be defined using the TNM classification of the American Joint Committee on Cancer (T describes tumour characteristics, N describes lymph node involvement, and M describes distant metastases).7 Patients with lymph node involvement and metastases have a much worse prognosis. Patients with early stage tumours have a greater than 90% five year survival rate, whereas those with lymph node disease have around a 30% five year survival rate.

4 How might this condition be managed?

Short answer

Within the United Kingdom, all patients with a histological diagnosis of SCC should be discussed at a skin cancer multidisciplinary team meeting. Surgical excision, which is normally carried out by plastic surgeons or dermatologists, is the gold standard. The aim of treatment is complete excision with 4 mm margins at least. Patients are followed up for two to five years, depending on the risk of recurrence.

Long answer

The British Association of Dermatologists published updated guidelines for the management of primary cutaneous SCCs in 2009 (table 2).8

Table 2

 Summary of treatment options for primary cutaneous squamous cell carcinoma (SCC)

View this table:

Site—High risk lesions are those that arise on the ear, lip, or non-sun exposed sites; lesions in areas of radiation, thermal injury, chronic inflammation, and chronic ulceration (Marjolin’s ulcers); lesions found in chronic draining sinuses; and SCC in situ.

Diameter—Tumours of 2 cm or more are twice as likely to recur locally and three times as likely to metastasise.

Depth—Tumours with a depth of more than 4 mm or those that extend into the subcutaneous tissue are more likely to recur locally and metastasise.

Histology—Poorly differentiated tumours have double the risk of local recurrence and triple the rate of metastasis. Certain histological subtypes (acantholytic, spindle, or desmoplastic subtypes), and recurrent SCCs are considered high risk.

Host immunosuppression—Tumours that develop in immunosuppressed patients are considered high risk.7

Single complete surgical excision with 4 mm margins has a 95% five year cure rate. Mohs’ micrographic surgery (repeated surgical excision of thin layers of tissue using en face histological mapping until a complete tumour-free plane of tissue has been visualised) is marginally better than single complete surgical excision, with a 97% five year cure rate.9 Curettage and cauterisation of small slow growing well defined tumours show a five year recurrence rate of 2%, but success is operator dependent. Radiotherapy gives a five year cure rate of 90%, but is not a good choice for lesions on the legs of elderly people because of poor wound healing. Cryotherapy may be suitable if performed in specialist centres.

Patients with high risk lesions are followed up for five years, whereas those with low risk lesions are followed up for two years.

Patient outcome

Our patient had a 3 cm mass in her left groin. A punch biopsy was performed on one of the lesions on her left shin and fine needle aspiration was performed on the groin lymph node. Histological analysis showed that she had SCC with lymphatic spread. A staging computed tomogram showed no other metastases. Although she was 99 years old, she was relatively free of comorbidities and enjoyed a good quality of life. She went on to have the lesions excised from her leg and a left sided inguinal lymph node clearance. The surgical deficit was reconstructed with a split thickness skin graft. She will be followed regularly for five years as an outpatient to identify any recurrence.

Notes

Cite this as: BMJ 2012;345:e7409

Footnotes

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

  • Patient consent obtained.

References