38 CLINICAL
Can you identify these skin lesions ?
Patients are often worried that moles and blemishes are skin cancer . Can you identify these lesions and whether they require urgent referral ? Answers in the box below
1
A 75-year-old man has presented to you with this slow-growing lesion behind his ear . What is the most likely diagnosis ?
Squamous cell carcinoma .
Basal cell carcinoma . Bowen ’ s disease . Keratoacanthoma .
2
A 65-year-old man has presented with this lesion , which appeared about 12 weeks ago and has grown rapidly . What is it ?
Squamous cell carcinoma .
Basal cell carcinoma . Bowen ’ s disease . Keratoacanthoma .
3
A 50-year-old man has come to show you this lesion . He rarely comes to the surgery except to collect prescriptions for his immunosuppressants , which he takes regularly following a kidney transplant some years ago . What is it ?
Squamous cell carcinoma .
Basal cell carcinoma . Bowen ’ s disease . Keratoacanthoma .
4
A 76-year-old woman has come to show you this lesion on her leg – it has been growing slowly for a year or so . What is it ? Squamous cell carcinoma . Basal cell carcinoma . Bowen ’ s disease . Keratoacanthoma .
Answers 1 This is a basal cell carcinoma ( BCC ) which is a locally invasive malignancy . It does not metastasise distantly . BCCs are usually found on sun-exposed skin , particularly on the face , and in scar tissue . They present as nodules , often with visible blood vessels and may bleed and then heal . Refer routinely , or on the two-week system if delay would have a significant impact ( for instance , due to size or location ). 2 This is a keratoacanthoma , a benign tumour which will heal spontaneously if left alone . Typically the appearance is of a nodule shaped like a dome with a central plug of keratin . Despite the benign nature of a keratoacanthoma , it is easily mistaken for a squamous cell carcinoma and so all suspected keratoacanthomas should be referred on the two-week suspected cancer pathway . 3 This is a squamous cell carcinoma ( SCC ), a malignancy usually found in older or immunocompromised patients . In the latter group it presents more aggressively and at a younger age . SCCs are commonest on sun-exposed sites and present as a firm area of induration , which may ulcerate . Referral is on the two-week suspected cancer pathway . 4 This is Bowen ’ s disease , a precursor of squamous cell carcinoma ( SCC ) which will convert to SCC in around 3 % of cases . It presents as well defined patches or plaques with a pink appearance , usually in areas exposed to the sun . With time they may become scaly or ulcerated . Referral is to a normal dermatology clinic rather than on the two-week pathway .
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