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Painful eyebrow lesion concerns patient
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A 76-year-old white male presented to the clinic with a lesion on the left upper eyebrow. The patient was concerned because the lesion was painful to the touch, and he had a history of skin melanomas. The lesion was of recent onset, and the patient said the pain felt as if there was a “thistle” in his eyebrow. The patient wanted to have the lesion removed because of the severe pain and his history of skin cancer.
The patient’s medical history was significant for malignant neoplasms of the skin, actinic keratosis, seborrheic keratosis, eczema and hyperlipidemia. Medications included low-dose aspirin (81 mg daily), simvastatin (20 mg at bedtime), triamterene-hydrochlorothiazide (37.5 mg-25 mg daily) and an albuterol inhaler (as needed). He was allergic to nonsteroidal anti-inflammatory drugs.
Ross F. English
Leonid Skorin Jr.
The patient’s ocular history was significant for cystoid macular edema and ocular hypertension in the right eye, both secondary to ischemic central retinal vein occlusion. He also had 1+ to 2+ nuclear sclerotic cataracts in both eyes. Entering acuities were finger counting at 6 feet in the right eye and 20/20- in the left. There was a positive afferent pupillary defect in the right eye. Ocular motilities were full with no discomfort or diplopia. Applanation tonometry revealed 20 mm Hg and 18 mm Hg in the right and left eye, respectively.
The slit lamp exam revealed a pink scaly lesion with pearly margins on the left upper brow. The lesion was not raised and was sensitive to the touch. The total lesion size was 13 mm x 5 mm. Excision biopsies are the preferred method for removal of any lesions that are too large or too deep for a punch or shave biopsy (Alguire et al.).
To remove the lesion with an excisional biopsy, an ellipse was drawn with a surgical marking pen around the lesion, and lidocaine 2% with 1:100,000 epinephrine was injected for anesthesia and hemostasis. The area was then sterilized and draped, and a surgical blade was used to make the incision. Prior to excising the lesion a single suture was placed at 6 o’clock to orientate the tissue for the pathologist. Bleeding was controlled with cauterization. The wound was closed with interrupted 6-0 silk sutures, and the specimen was sent to pathology.
Lesion marked in an elliptical fashion prior to excision.
Images: English RF
Excised lesion with suture placed for orientation.
Our working diagnosis was suspected malignant lesion of unknown etiology. Histopathologic evaluation revealed irregular nests of atypical squamous cells extending from the dermis, leading to the diagnoses of grade 1 to 2 (out of 3) invasive squamous cell carcinoma (SCC). Actinic keratosis was also focally noted at the margin. Inflamed stroma was present, explaining the pain associated with the lesion. The lesion appeared completely excised, with the closest lateral inked margin being 1.2 mm from the biopsy edge. With the history of previous skin carcinomas, however, and the presence of actinic keratosis, the patient needs to be closely monitored for future development of additional cancerous lesions.
Description, epidemiology
SCCs make up 20% of new skin cancers diagnosed each year in the U.S. This correlates to approximately 200,000 new cases each year. An estimated 1,300 to 2,300 people ultimately die each year from nonmelanoma skin cancer. A vast majority of these deaths can be attributed to metastatic SCC (Slasche).
SCC forms from actinic keratoses, which usually develop from long-term exposure to ultraviolet A and B radiation, mostly from sunlight (Alam et al., Slasche). Although the incidence is somewhat disputed in the literature, estimates of actinic keratoses converting to SCC range from 0.1% to 10% (Salasche). SCC is strongly associated with sun exposure, age and fair-skinned individuals. It also occurs most commonly in males (Maguire and Smith).
This histopathologic image, magnified 100x, shows invasive squamous cell carcinoma.
One-week postoperative visit after suture removal. There is no evidence of infection, and the
surgical site is healing well.
Actinic keratoses often present as scaly lesions that can be difficult to see because of their pink appearance. SCC can present as nodular, ulcerating or as a cutaneous horn (Kanski). SCCs are firm, pink papules that are either smooth or keratotic (Alam et al.). SCCs are often asymptomatic. A change in size and shape, itching, tenderness and bleeding are also symptoms of SCC (Askari, Schram et al.).
Only one study has evaluated the prevalence of pain with SCC. Mills and colleagues studied 576 biopsy-proven nonmelanoma skin cancers for pain and itching. They found a 39.8% prevalence of pain in SCC. Furthermore, they found pain to be a unique factor that can help differentiate SCC from basal cell carcinoma. Although not commonly cited in the literature, this study suggests that pain needs to be on the clinician’s radar when it comes to SCC.
Treatment
In 90% of cases, excision can eliminate local tumors, as was done in our case, with no further treatment. For inoperable tumors, radiation treatment is preferred (Alam et al.).