In the store-and-forward teledermatology modality, there is a transfer of patient medical information electronically (including history and visual data) obtained in one location to a provider who is in another location (Roman & Jacob, 2015). The construct of the TeleDermatology ViewPoint column is such that cases are presented in a standardized teledermatology reader format reflective of an actual teledermatology report.
TELEDERMATOLOGY READER REPORT1
History
Chief complaint: Presenting for diagnosis of skin lesion and therapeutic options.
History of present illness: A 56-year-old man with a 30-pack-year history of smoking and chewing tobacco presents with a well-circumscribed, crusted keratotic exophytic nodule on the lower lip that had been removed 6 years ago but slowly grew back.
Prior treatment: details unknown. Prior biopsy: yes. Skin history: lesion on the lower lip. No other history of skin cancer.
Image Quality Assessment
Fully satisfactory.
TELEDERMATOLOGY IMAGING READER REPORT
There is one image provided with this consult. The image shows a well-circumscribed, crusted keratotic exophytic nodule on the lower lip appearing >2.0 cm (see Figure 1).
INTERPRETATION OF IMAGES
Lesion A
Findings
The morphology of the lesions, distribution, and history are characteristic for squamous cell carcinoma (SCC).
RECOMMENDATIONS
Refer to dermatology for biopsy to confirm diagnosis and determine treatment.
CLINICAL PEARL
Cutaneous SCC (cSCC) is the second most common nonmelanoma skin cancer, following basal cell carcinoma, and refers to a keratinocyte cancer where mutated cells grow beyond the epidermis. Clinically, cSCC presents as scaly or crusted papules, plaques, or nodules that can grow over weeks to months. They can ulcerate, are often painful, and are commonly located on sun-exposed areas, particularly the face, lips, ears, hands, forearms, and lower legs (Oakley, 2015). Lip SCC accounts for 12% of all cancers of the head and neck region, with most localized to the lower lip (Elmas et al., 2019). Risk factors include sun exposure, age, fair skin, and environmental exposures. Environmental exposures associated with cSCC include alkylating agents and substances found in tobacco products such as arsenic, polycyclic aromatic hydrocarbons, and nitrosamines (Que et al., 2018). These substances promote DNA mutations by complex mechanisms that can lead to the increased risk of cancer. Therefore, smoking and chewing tobacco and alcohol use are major risk factors for oral SCC and are present in 90% of the cases. Patients who smoke or chew tobacco should receive regular oral examinations and be counseled on tobacco use cessation (Rivera, 2015).
Diagnosis of cSCC is based on clinical features, which can be aided by dermoscopy, and is confirmed pathologically by diagnostic biopsy or after excision (Oakley, 2015). Treatment for cSCC is nearly always surgical excision with a 3- to 10-mm margin (Oakley, 2015). Histological confirmation of clear margins is important for the reduction of local recurrence (Thiem et al., 2020). Other therapeutic options for low-risk tumors include cryotherapy, shave, curettage, and electrocautery (Oakley, 2015). Screening with clinical examinations, ultrasound, and sentinel lymph node biopsies may be important in high-risk tumors, such as this patient's lesion that appears >2.0 cm on the lower lip, as they have a twofold increased risk of cSSC recurrence, a threefold increased risk of metastasis, and a 19-fold increased risk of death from cSCC compared with tumors < 2 cm (Que et al., 2018). High-risk tumor management options include standard excision with wider margins, Mohs micrographic surgery, and radiation therapy (Bander et al., 2019). Most cSCCs are cured by treatment, but about 50% of people at a high risk experience recurrence within 5 years of the first tumor and are at an increased risk for other skin cancers as well. Regular self-examinations and examinations by a healthcare professional are recommended (Oakley, 2015).
NURSING PERSPECTIVE
Nurses play an important role in the prevention and initial detection of cSCCs. Nurses can counsel patients on preventive measures such as tobacco use cessation, UV protection/exposure reduction, wearing of protective clothing, sunscreen application, and avoidance of indoor tanning (Oakley, 2015). Nurses can also screen for cSCC by performing oral and skin examinations and referring to dermatology when indicated.
REFERENCES