Four Unusual Clinical Presentations of Cutaneous Squamous Cell Involving Distal Extremities

Scott Jaros presents background and details on his case series, Unusual Clinical Presentations of Cutaneous Squamous Cell Involving Distal Extremities in Four Patients: The Importance of Tissue Sampling, written in concert with Paul B. Googe, MD; Jayson R Miedema, MD; and Carolyn Ziemer, MD, MBA. Read the full article here.
 

Transcript:

My name's Scott Jaros. I'm a fourth-year medical student at UNC. I have a BS degree currently, and I worked on this paper with Dr. Googe, Dr. Ziemer and Dr. Miedema. The case series revolved around four cases that came through our hospital and that all ended up being cutaneous squamous cell carcinoma that originally presented as a non-healing wound or infection. And all these cases did not respond to their original treatment, which prompted biopsy. And this ultimately led to the diagnosis of squamous cell carcinoma.

A couple of things, just starting from circumstance. Like I said, these four cases over a year and a half passed through the hospital system and were all severe cases of squamous cell carcinoma, which sparked the interest of our department. The samples are often sent to Dermpath to rule out items like ulcer or atypical infection, so that also helped feed it through to us. And then once we saw these cases, we wanted to take a closer look and see what similarities we found between the four cases. And once we did that, we saw that this would be a worthy paper to try and publish because it kind of reemphasizes the importance of tissue biopsying of ulcers and wounds and other lesions that are unusual or not responding to the treatment for their initial diagnosis. It potentially can give clues or provide guidance for further treatment.

Nothing was particularly surprising, outside of the fact that the cases, some took longer than others. The first case with the scleroderma, that one took a lot longer just to diagnose. It was about two years, and then that mostly revolved around a lot of poor follow up, though, not necessarily error on the clinical side. But, still, the case was very surprising. But outside of that, nothing was too surprising in the cases.

Some of the key things that we hope that people take away from this study, first and foremost, that it's really important to biopsy a wound or an infection that's not responding to treatment. And this is a pretty standard practice, but this case really emphasizes that well. In many cases, like with an atypical infection, it can be guiding, but it can also reveal something that wasn't originally on the differential diagnosis or at least a lot lower on the differential, like squamous cell carcinoma. We feel like this is really important for caretakers and those who work with wounds and infections. The vast majority of the time they're going to see something that's inflammatory or benign, but occasionally you will get something more malignant.

And then ulcers and wounds on extremities are common, and the teaching is to think horses when you hear hooves, but any provider that sees a lot of common things will occasionally come by a zebra. And then lastly, some of our patients were immunosuppressed with these non-healing wounds or infections and ended up having squamous cell carcinoma. So just to highlight that the immunosuppressed are a population that are at higher risk of potentially coming by one of these ulcers.

It would be interesting to see if someone quantified the incidents of malignancy in patients presenting with skin changes that were not related to their original differential and seeing just how often that actually happens. And then more in a broader sense, there will obviously continue to be advances in treatment for cutaneous malignancies, even at more advanced stages. Checkpoint inhibitors, for example. And it's likely that these will continue to advance and provide additional options to treat similar types of malignancies at these more severe stages.