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October 2004
By Stephen M. Schleicher, MD, and Robert
S. Levine, DO
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CASE:
A 76-year-old woman is sent to your emergency department
by her son, who reports that he has noted a progressive "mental
status change" and that she "sounded funny" on the telephone.
The patient lives alone and has a history of senile dementia
(Alzheimer's type), hypertension, cataracts, and hypothyroidism.
Cutaneous examination reveals a fungating tumor of her neck.
When questioned about this lesion, she tells you it has been
there for "quite a while."
WHAT IS YOUR DIAGNOSIS?
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The patient has a squamous cell carcinoma (SCC), a malignant
tumor of epithelial keratinocytes. The majority of cases are
linked to chronic sun exposure. Other causes include cigarette
smoking, ionizing radiation, and arsenic ingestion. Sites at
greatest risk are the lower lip, ears, scalp and hands. Highly
differentiated SCCs present as firm, solitary papules, plaques,
or nodules with keratotic scale. These lesions, which frequently
erode or ulcerate, may have a central crust surrounded by a
firm, elevated margin. Poorly differentiated SCCs do not show
signs of keratinization. Punch or shave biopsy is necessary
to confirm the diagnosis. Treatment modalities range from cryosurgery
and curettage for low-risk lesions to surgical excision for
tumors with significant risk of metastasis. Radiation therapy
is well suited for larger lesions in the elderly. |
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Dr. Schleicher is director of the DermDx
Centers for Dermatology of Northeastern Pennsylvania as well
as Schleicher Dermatology Associates in Bonita Springs, Florida.
He is a clinical instructor of dermatology at the Philadelphia
College of Osteopathic Medicine, at Kings College in Wilkes-Barre,
Pennsylvania, and at Arcadia University in Glenside, Pennsylvania.
He is also a member of the EMERGENCY MEDICINE editorial board.
Dr. Levine is a family practice resident at the Long Beach
Medical Center in Long Beach, New York.
Emerg Med 36(10):7-8, 2004
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