Clinical image description

An 86 year-old woman was admitted in the emergency unit with a severe deterioration of her general condition. She was found in her apartment lying on the floor for an unknown period of time. She had no known medical history or treatment. She lived alone without relatives. She suffered from nosocomephobia (fear of hospitals), but was regularly visited by a nurse to treat a 10-year old tumor that she refused to have examined by a doctor.

Upon admission, she presented a large, foul-smelling, oozing, bleeding, and decaying right substernal poly-lobed tumor (Figure 1A). She was pale, with a Body Mass Index of 15 kg/m2 and had normal parameters. She had severe normocytic anemia (serum hemoglobin 4.9 g/dl), and inflammatory syndrome (c-reactive protein 180 mg/l; neutrophil count 29000/μl). Bacterial cultures of the purulent oozing material revealed ampicillin-sensitive Staphylococcus aureus. She was started on intravenous Amoxicillin-clavulanate. Chest Magnetic Resonance Imaging revealed the depth of the tumor, reaching the anterior periosteum of the manubrium, invading the fat anterior of the trachea, without cleavage plane between the lesion and the sternocleidomastoid muscle tendons (Figure 1B). Pathological analysis revealed a Spindle Cell Squamous Cell Carcinoma (SCSCC).

The patient died from respiratory failure secondary to the physical compression of the tumor on the trachea, 7 days later.

SCSCC is 1 of 8 types of cutaneous Squamous Cell Carcinomas (SCC). SCC are the second most common nonmelanoma skin cancers and represent 75% of all deaths from skin cancers, excluding melanoma. SCC incidence is increasing [1]. Most SCC develops in areas of solar or ionizing radiation of elderly patients [2]. Anti-PD-1 antibodies are the first-line systemic treatment for locally advanced SCC when curative surgery or radiation are not feasible [3]. Even at an advanced stage, palliative surgery or RT could have improved our patient’s quality of life.

Figure 1: A: Picture taken upon admission showing the voluminous bleeding cutaneous spindle cell carcinoma. B: Transversal chest T2-weighted Fat Saturation Magnetic Resonance Imaging showing the exophytic tumor infiltrating the neck to the trachea.

References

1. Que SKT, Zwald FO, Schmults CD. Cutaneous squamous cell carcinoma: Incidence, risk factors, diagnosis, and staging. J Am Acad Dermatol. 2018; 78: 237-247.
2. Kallini JR, Hamed N, Khachemoune A. Squamous cell carcinoma of the skin: Epidemiology, classification, management, and novel trends. Int J Dermatol. 2015; 54: 130-40.
3. Stratigos AJ, Garbe C, Dessinioti C et al. European interdisciplinary guideline on invasive squamous cell carcinoma of the skin: Part 2. Treatment. Eur J Cancer. 2020; 128: 83–102.