A 65-year-old man comes to the office due to a nonhealing ulcer on the left upper extremity. For the last 2 months, he has had an enlarging ulcerated lesion, with intermittent bleeding and itching. In the last 3 weeks, the patient has also noted local numbness, paresthesias, and burning pain. He does not recall any injury prior to the onset of symptoms. He has good appetite and reports no weight loss. There is no fever, dyspnea, or cough. The patient has a history of renal transplantation and takes an appropriate immunosuppressive regimen. He does not use tobacco, alcohol, or illicit drugs. Vital signs are normal. Physical examination of the lesion is shown in the image below. The remainder of the examination is unremarkable. Which of the following is the most likely diagnosis?

Question

A 65-year-old man comes to the office due to a nonhealing ulcer on the left upper extremity.  For the last 2 months, he has had an enlarging ulcerated lesion, with intermittent bleeding and itching.  In the last 3 weeks, the patient has also noted local numbness, paresthesias, and burning pain.  He does not recall any injury prior to the onset of symptoms.  He has good appetite and reports no weight loss.  There is no fever, dyspnea, or cough.  The patient has a history of renal transplantation and takes an appropriate immunosuppressive regimen.  He does not use tobacco, alcohol, or illicit drugs.  Vital signs are normal.  Physical examination of the lesion is shown in the image below.  The remainder of the examination is unremarkable.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

This patient has a cutaneous squamous cell carcinoma (SCC). SCC typically forms an enlarging nodule in sun-exposed areas. The lesions often become keratinized (with a thickened, rough surface) or ulcerate with crusting and bleeding. In addition, SCC can display early perineural invasion, causing regional neurologic symptoms (eg, numbness, paresthesias). Risk factors for SCC include sunlight exposure, fair skin, chronic inflammation or scar formation, and ionizing radiation exposure. SCC is especially common in patients who have a history of organ transplant and are on chronic immunosuppressive therapy. SCC in immunosuppressed patients is typically more aggressive, with an increased risk of local recurrence and regional metastasis. (Choice A) Basal cell carcinoma (BCC) characteristically presents as a pearly, flesh- or pink-colored nodule with telangiectatic vessels and is usually found on the head or neck. BCC is the most common skin malignancy in the general population; however, SCC occurs more commonly among immunosuppressed patients and more commonly on the extremities, and it is more likely to cause neural invasion. Basal cell carcinoma (Choice B) Disseminated cryptococcosis is usually seen in immunosuppressed patients. The skin is the most common site. It presents as multiple, discrete, flesh- to red-colored papules of varying size with slight central umbilication. papules (Choice C) Kaposi sarcoma is most commonly seen in the setting of coinfection with HIV and human herpes virus 8. The lesions typically begin as papules and later develop into plaques or nodules. The color can change from light brown to violet, and patients often have multiple lesions. (Choice D) Melanomas are also seen with increased frequency in transplant patients. They are most often pigmented and are characterized by asymmetry, irregular border, variegated color, diameter >6 mm, and evolution in size and appearance over time. Educational objective: Squamous cell carcinoma (SCC) is the most common skin malignancy in patients on chronic immunosuppressive therapy for a history of organ transplant. SCC in immunosuppressed patients is more aggressive, with an increased risk of local recurrence and regional metastasis. References: Factors predictive of recurrence and death from cutaneous squamous cell carcinoma: a 10-year, single-institution cohort study. (http://www.ncbi.nlm.nih.gov/pubmed/23677079)

A 65-Year-Old Man Comes to the Office Due to a Nonhealing