Case 7 Malignant Skin Lesion



W. Kelsey Snapp, Albert S. Woo, and Antonio Cruz

Case 7 Malignant Skin Lesion

Case 7 A 68-year-old male presents with a lesion on the left side of his face. He reports that the growth has been present for over a year, is painless, and occasionally bleeds.



7.1 Description




  • Large, eroded, pearly pink plaque with telangiectasia located on the left temple, involving the temporal hairline, and demonstrating evidence of ulceration.



  • There is significant concern for malignancy.



7.2 Work-Up



7.2.1 History




  • Length of time the lesion has been present



  • Associated symptoms: Pain, scabbing, itching, bleeding, and hyperkeratosis



  • Sun exposure history, tanning bed use



  • History of facial surgery, especially surrounding the nose




    • Previous surgery may affect reconstructive options



    • Primary tumor versus recurrent tumor




      • Previous treatment with cryotherapy, topical medications, electrodesiccation and/or curettage



      • Scar in area of malignancy



  • Complicating comorbidities: Cardiopulmonary/peripheral vascular disease, diabetes, tobacco product use, steroid use, anticoagulation, and chemotherapy



  • Supplementation with vitamin E, fish oil, krill oil, omega, and garlic



  • History of radiation, immunosuppression (organ transplant recipient, AIDS)



  • Personal or family history of skin cancer



  • Genetic conditions: Xerodermapigmentosum, Gorlin’s (nevoid basal cell) syndrome, albinism



7.2.2 Physical Examination




  • Detailed evaluation of affected area and surrounding face/neck to assess the lesion with or without dermatoscopic analysis/magnification




    • Characteristics of affected area (e.g., hair bearing, adjacent skin laxity, and pigmentation)



  • Skin lesion findings




    • Size, color, shape of lesion, skin irregularity, hyperkeratosis, and ulceration



    • Confirm absence of involvement of deeper structures (e.g., parotid and facial nerve)



  • Lymph node examination to assess for signs of metastatic disease



  • Full body integument examination



7.2.3 Diagnostic Studies




  • Establish a diagnosis: If patient presents without previous treatment, a biopsy should be performed.



  • Full-thickness incisional versus excisional biopsies may be performed




    • If the concern is for an atypical pigmented lesion, an excisional or shave biopsy should be performed to evaluate as much of the lesion as possible to minimize sampling error



    • Avoid shave biopsies of a portion of a pigmented lesion as they may lead to incomplete assessment of the lesion, particularly in melanoma, where the depth of a tumor is critical to prognosis



    • Shave biopsyis an acceptable method of assessment if the concern is for a nonmelanoma skin cancer (basal or squamous cell carcinomas)



  • Imaging may be necessary after an initial diagnosis is established, especially if deeper tissue invasion is a concern or in lesions of the scalp where one is suspicious of possible bony penetration




    • Magnetic resonance imaging (MRI): Useful adjunct to determine extent of tumor and lymph node status in cases of aggressive tumor histology (e.g., perineural invasion)

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Jul 17, 2021 | Posted by in General Surgery | Comments Off on Case 7 Malignant Skin Lesion
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