An 87-year-old woman is brought to the office for a lesion on her back. She lives by herself and is very reluctant to seek medical care. Her daughter, who is visiting from out of state, found a foul-smelling discharge coming from the lesion. The lesion has gradually enlarged over the past 3-4 years, and the patient has cleaned it with over-the-counter antiseptics. She has a history of sunburn in the area many years ago. She has no pain or fever. The patient has no other medical conditions. She does not use tobacco or alcohol.
The lesion is shown in the image below. She has no other masses or lymphadenopathy.

Which of the following is the most likely diagnosis?

Question

An 87-year-old woman is brought to the office for a lesion on her back.  She lives by herself and is very reluctant to seek medical care.  Her daughter, who is visiting from out of state, found a foul-smelling discharge coming from the lesion.  The lesion has gradually enlarged over the past 3-4 years, and the patient has cleaned it with over-the-counter antiseptics.  She has a history of sunburn in the area many years ago.  She has no pain or fever.  The patient has no other medical conditions.  She does not use tobacco or alcohol.
The lesion is shown in the image below.  She has no other masses or lymphadenopathy.

Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

This patient's presentation suggests cutaneous squamous cell cancer (SCC), the second-most common skin cancer in the United States after basal cell carcinoma. Risk factors for cutaneous SCC include increasing age, light skin color, sun exposure (UV light), chronic skin inflammation (eg, burns, scars, ulcers), and ionizing radiation exposure (eg, cancer or acne therapy). Cutaneous SCC can occur on the head, neck, trunk, extremities, oral mucosa, or anogenital areas. Poorly differentiated SCC typically appears as fleshy, soft, and granulomatous papules and nodules with less hyperkeratosis than seen in well-differentiated lesions. The lesions can ulcerate, bleed, become necrotic, or cause pain and pruritus. Biopsy can confirm the diagnosis. (Choice A) Seborrheic keratosis is a benign hyperpigmented lesion that usually appears on the trunk, head/neck, or extremities. The lesions typically appear "stuck on" with sharply demarcated papules and plaques. Seborrheic keratosis (Choice B) Malignant melanoma is characterized by pigmented lesions with asymmetric shape, irregular borders, color variation (eg, black, brown), increasing diameter (>5 mm), and evolution in appearance over time. Nonpigmented melanoma may occur but is uncommon. Malignant melanoma (Choice C) Cutaneous warts (verruca vulgaris) can grow irregularly and ulcerate; they occur in sun- exposed areas, similar to SCC. Cutaneous warts are most commonly due to human papillomavirus and usually develop faster than the 3-4 years seen in this patient. verruca vulgaris (Choice D) Pyogenic granuloma usually presents as a small red papule that grows rapidly over weeks to months before stabilizing. The lesion is friable and can bleed with minor trauma. SCC is usually more hyperkeratotic and not as friable as pyogenic granuloma. Pyogenic granuloma Educational objective: Poorly differentiated cutaneous squamous cell carcinoma may appear as fleshy, soft, and granulomatous papules and nodules with less hyperkeratosis than seen in well-differentiated lesions. __________ References: Diagnosis and treatment of basal cell and squamous cell carcinoma. (http://www.ncbi.nlm.nih.gov/pubmed/22962928)

An 87-Year-Old Woman Is Brought to the Office for a Lesion