Metastatic Squamous Cell Carcinoma

Shortly after arriving from Puerto Rico, a 59-year-old man presented with right-sided frontal head pain and decreased vision in his right eye. He was concerned about a “sore” that first developed 9 months earlier on his head. The patient denied fever, chills, and syncope.

A 9 × 11-cm, deeply ulcerated lesion was evident on the right frontotemporal region of the head. The lesion was malodorous, with necrotic tissue and exposed cranial bone. A branch of the temporal artery was visible; with each pulsation of the artery, about 0.5 mL of cerebrospinal fluid was emitted (A, arrow). Another lesion that measured 233-cm and involved subcutaneous tissue was found in the right infra-auricular region.

The patient was awake, alert, and oriented. His vital signs were stable, and he answered questions appropriately. No adenopathy was found. Left eye visual fields were intact; the right eye exhibited ptosis with intact extraocular muscles and a mild right peripheral visual field deficit. Breath sounds were clear; pulse was regular. The abdomen was soft and nontender; bowel sounds were present. The patient's extremities were warm and without cyanosis or edema. No focal deficits were noted on the neurologic examination.

A noncontrast CT scan of the head was obtained. Soft tissue ulceration, mottled eroded bone with focal dehiscence, and epidural air and fluid were demonstrated in the right frontal region (B, arrow). A biopsy of the frontotemporal lesion was performed. Metastatic squamous cell carcinoma (SCC) of the skin with involvement of the right globe, right orbital floor, and posterior cervical neck was diagnosed.

Drs Michael T. Parke and Brian D. Kuronya of Bethlehem, Pa, write that SCC-a malignant tumor of the keratinizing cells of the epidermis-is the second most common skin cancer in the United States; more than 100,000 new cases are diagnosed each year. The mean age at diagnosis is 68.1 years in men and 72.7 years in women.^1,2

SCC of the skin presents as a hyperkeratotic plaque, papule, or patch that is commonly confined to sun-exposed regions of the body. About 60% of SCCs arise from actinic, or solar, keratoses, which appear as areas of hyperkeratosis with surrounding erythema or, rarely, as macular erythematous patches. The annual risk of transformation to SCC is less than 1 in 1000.²

About 3% to 5% of SCCs metastasize. Factors that affect metastatic potential include the tumor's location, size, depth of invasion, and recurrence; and the patient's age and cumulative UV exposure.^1,3 Most metastatic SCC lesions originate from actinic keratoses.

Sun exposure is the leading risk factor for actinic keratosis and SCC. Tanning beds are also suspected; studies with mice have demonstrated an association between tanning beds and skin damage.⁴ Other risk factors for SCC are photochemotherapy, thermal injury, chemical carcinogens, human papillomavirus (strains 16, 18, 30, 33) infection, and radiation exposure.⁵

Although surgical excision is the treatment of choice for SCC, a 95% cure rate for lesions smaller than 2 cm has been achieved with electrodesiccation, cryosurgery, or curettage.⁶ Multiple actinic keratoses need to be treated. Topical 5-fluorouracil, which causes necrosis of the lesion and reepithelialization of the affected area, may be used; dermabrasion, radiotherapy, and Mohs surgery are other options.

Regularly follow up patients who have been treated for SCC. Assessment of the treated area, full-body and lymph node examinations, and evaluations of other suspicious lesions are recommended.

Advise your patients to perform self-examinations, avoid excessive sun exposure, and routinely apply sunscreen with a sun protection factor of 15 or higher.

This patient's tumor and affected skull were resected. A skull prosthesis was placed, skin grafting was performed, and radiation therapy was given. The disease recurred, and the patient's prognosis is poor.

REFERENCES:1. Habif T. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. 3rd ed. St Louis: Mosby–Year Book; 1996.
2. Murphy GP. Clinical Oncology. 2nd ed. Atlanta: American Cancer Society; 1995.
3. Fitzpatrick TB. Color Atlas and Synopsis of Clinical Dermatology. 3rd ed. New York: McGraw-Hill; 1997.
4. Van Weelden H, van der Putte SC, Toonstra J, van der Leun JC. UVA-induced tumours in pigmented hairless mice and the carcinogenic risks of tanning with UVA. Arch Dermatol Res. 1990;282:289-294.
5. Fauci AS. Harrison's Principles of Internal Medicine. 14th ed. New York: McGraw-Hill; 1998.
6. Odom R, James WD, Berger TG. Andrews' Diseases of the Skin: Clinical Dermatology. 9th ed. Philadelphia: WB Saunders Company; 2000.

FOR MORE INFORMATION:

• Andreoli TE. Cecil Essentials of Medicine. 4th ed. Philadelphia: WB Saunders Company; 1997.

• Tierney LM Jr. Current Medical Diagnosis and Treatment 2000. 39th ed. New York: McGraw-Hill; 2000.