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 …

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