Managing skin cancer below the knee
The nodule continued to grow and he became disillusioned. He asked for referral for a third opinion. I then saw him some 3 months after his first assessment. He demonstrated a large friable lesion 27 mm across at its maximum diameter. There had been no biopsy taken up to this point. I aggressively debulked the lesion including all apparent pathologic tissue. Histology confirmed squamous cell carcinoma (SCC).
He had ipsilateral inguinal nodes on presentation. Fortunately these were reactive and settled with antibiotics.
Being a keen amateur photographer, Mr RR had captured the tumour at various stages in its growth..
Following histologic confirmation, the SCC was widely excised. There was no residual tumour on histology. The defect was closed with a reducing opposed multilobed (ROM) flap repair. This closure technique produces better outcomes than traditional flaps and grafts for medium sized defects below the knee.
As is usual following ROM flap repair, Mr RR was mobilising the same day. He was advised to elevate his legs when seated. Two months postsurger.
Summary of important points
• Histology of a KA can also be difficult. Dermatopathologists frequently debate whether a lesion is KA or SCC. The histologic differences can be subtle. You may choose to have uncertain reports reviewed by an experienced dermatopathologist.
• The KA/SCC dilemma is best managed by treating all KAs as if they were well differentiated SCCs. Most authorities now regard a KA as a malignancy; although with slim metastatic potential.
These lesions can be removed by excision or curettage. This overcomes any clinical dilemma and eliminates the risk of a SCC developing a metastasis while it is ‘watched’.
• SCCs at higher risk of developing metastases are recurrent tumours, those over 2 cm, and those on the
ear, lip, eyelid or scalp. Transplant and immunosuppressed patients are also at increased risk of metastatic spread from their cutaneous SCC.
• One should not be avoiding excision because the defect would be too large to close. If the tumour needs excision, it needs excision. Delaying excision because defect closure is problematic is not acceptable. Consider referral either before or after biopsy as appropriate
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