A Case of Squamous Cell Carcinoma of the Scalp in an African Man

A 37-year-old man presented with a chronic ulcer on the left side of his scalp. He was a native of Guinea, Africa, who spoke only French; an interpreter translated for him. He stated that the lesion had begun 4 years ago as a small pimple, for which he did not seek medical advice or treatment. He believed that doctors practice “black magic,” and he instead used herbal home remedies, with no improvement. He had visited France for an evaluation of the skin lesion but had received only a laboratory workup. Since then, the lesion had progressively enlarged, without healing, and had started to ulcerate.

The man denied having pharyngitis, fevers, lymphadenopathy, chills, night sweats, or weight loss. He was a nonsmoker with no significant past medical or family history. Physical examination found a 5 × 5 × 1-cm raised, lobulated lesion overlying the normal skin surface, with central ulceration, on the left temporoparietal area (Figure 1). No structural deformity was noted, and the patient’s neurovascular status was intact. The lesion produced serosanguineous drainage without acute signs of infection. However, the purulent, fungating ulcer contained fibrotic borders with some areas of granulation and necrotic tissue. In addition, a left occipital lymph node was palpable.

Figure 1. Initial presentation of the patient with an ulcerative, fungating mass on the left temporoparietal area.

Figure 2. Head CT scan without contrast showed a large, superficial mass in the left parietal region, extending to the level of the calvaria.

He was admitted to a community hospital for further evaluation. A computed tomography (CT) scan without contrast of the head showed a large, superficial mass in the left parietal region, which extended into the level of the calvaria (Figure 2). There was no evidence of mass effect, hemorrhage, or infarction, and distal metastases were excluded.

Figure 3. Intraoperative excisional biopsy of a 6 Å~ 7-cm mass.

Three days after admission, an incisional biopsy of the left ulcerating scalp mass was performed. In addition, the left occipital lymph node was biopsied. Histopathologic evaluation of the scalp mass, which measured 6 × 7 cm (Figure 3), demonstrated an infiltrating, well-differentiated, ulcerated squamous cell carcinoma (SCC) (Figures 4 and 5). Evaluation of the excised left occipital lymph node revealed metastatic carcinoma (Figures 6 and 7). The patient recovered without complications, with a clean, dried dressing over the open wound.

Figure 4. Histopathologic slide of the gross specimen with normal epidermal cells with infiltrative squamous cells, as seen in the lower right margin.

Figure 5. High-power magnification of the gross specimen showing cellular dysplasia and keratin pearl, characteristic of SCC. Intercellular bridges are visible throughout.

Figure 6. Histopathologic slide of the left occipital lymph node biopsy specimen demonstrating germinal centers and lymphoid nodules.

Figure 7. High-power magnification of the left occipital lymph  node biopsy specimen demonstrating infiltrative dysplastic squamous cells surrounded by lymphocytic cells.

On postoperative day 7, the patient returned to the operating room for a deep marginal re-excision to remove any tumor remnants and for a biopsy of the palpable left posterior cervical lymph node (Figure 8). Frozen sections demonstrated acute and chronic inflammation, with granulation tissue and fibrin, but without residual carcinoma. The posterior cervical lymph node revealed benign follicular hyperplasia without metastasis. The patient tolerated the procedures well, with a new dressing over the lesion.

Figure 8. Postoperative day 7, scalp mass incisional biopsy. Granulation tissue and fibrosis were observed.

On postoperative day 11, a vacuum-assisted closure dressing over the left scalp was applied to drain serosanguineous fluid. Eight days later, on postoperative day 19, the patient underwent a full-thickness skin graft using the skin from his left thigh to cover the open 7 × 9-cm, granulating wound (Figure 9). He also received ampicillin-sulbactam to prevent infection. Clean dressings covered both sites. He was reevaluated over the following 2 days (Figure 10) and did not report any distress. At 1-month follow-up, the wound was healing well (Figure 11), and the patient was scheduled to undergo adjuvant chemotherapy and radiation therapy.

Figure 9. Postoperative day 19, with the 7 Å~ 9-cm lesion showing improvement after placement of vacuum-assisted closure. Diffuse granulation tissue was appreciated.

Figure 10. Postoperative day 21, after skin grafting. Skin mesh using skin from the patient’s left thigh was applied over the granulated lesion.

Figure 11. At follow up 1 month postoperatively, the man’s wound was healing well.

DISCUSSION

SCC, also called squamous cell cancer or nonmelanoma skin cancer, is a malignant proliferation of the epidermal keratinocyte. Primary lesions most commonly occur on the face, neck, ears, hands, and arms, but metastases are uncommon.

SCC is the second most common skin cancer after basal cell carcinoma.¹ The incidence of SCC has increased as much as 200% in the past 3 decades in the United States.¹ The incidence varies geographically due to increased exposure to UV radiation.² Persons who live close to the equator tend to present at a younger age compared with those who live more distant from the equator. The highest incidence occurs in light-skinned people older than 40 years with extensive sun exposure. SCC is relatively rare in people of African or Asian descent. However, SCC in African people carries a higher mortality rate due to delayed diagnosis, because these lesions are more likely to occur in sun-protected areas, including the scalp. The majority of SCC cases in persons of African descent arise from existing inflammatory skin conditions^3,4 or burn injury.⁴

SCC occurs twice as frequently in men older than 50 years compared with women of the same age. Individuals with a first-degree relative with SCC may have an increased risk of developing the disease, because they share similar cutaneous phenotypes and environmental and genetic factors.⁵ The occurrence rate of cutaneous SCC increases with the duration and degree of immunosuppression and is higher in sunny climates. The direct effects of immunosuppressive agents and UV radiation may augment DNA damage, because the immune system cannot eradicate percutaneous skin changes, especially in persons with HIV, persons who have undergone an organ transplant, and persons on long-term corticosteroid therapy.⁶ Arsenic (from contaminated water), radon, and chemical exposure from cigarette smoking also may increase the risk of cutaneous SCC, but more studies are necessary to make a definitive association.⁷

A subset of patients presents with high-risk SCC, which includes lesions greater than 2 cm in size, lesions with an invasion depth greater than 4 mm, recurrent lesions, and metastasis to regional lymph nodes.^8,9 Because SCC has a higher mortality rate in the black population, prevention and early detection are critical.¹⁰

The method of management depends on diagnosis, lesion size, morphology, location, and patient preference.² Biopsy and histopathologic analysis aid in the diagnosis of suspected lesions. In addition, CT imaging and lymph node biopsies help rule out metastasis.¹¹ In our patient’s case, excision of the ulcerative, nonhealing lesion was the best treatment approach. It is important to note that excision to clear margins is helpful to prevent further complications. This is accomplished with pathologic evaluations of specimens obtained postoperatively. After clear margins are found, the next step is reconstruction using split-thickness skin graft.^12,13 Skin grafting usually is performed when defects are large and unsuitable for primary closure or a local flap.¹²

It is rare for a young African patient such as ours, without any autoimmune conditions, to present with metastatic SCC of the scalp. While the best management approach to cases of SCC is debatable, especially SCC of the scalp, we deemed the most effective treatment for our patient to be encouraging him to undergo elective surgery to a clear margin, followed by radiotherapy of the affected lymph nodes and adjuvant systemic therapy to prevent recurrence. In addition, an oncologic evaluation with close follow-up should occur to monitor for any signs of recurrence.

Nickul N. Shah, MD, is a 2016 medical graduate of the American University of Antigua College of Medicine.

Roland Purcell, MD, is an attending surgical physician at Interfaith Medical Center in Brooklyn, New York.

Albert Cooper, MD, is an attending surgical physician at Interfaith Medical Center in Brooklyn, New York.

David Roman, RPA-C, is a surgical physician assistant at Interfaith Medical Center in Brooklyn, New York.

References:

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Acknowledgement

The authors acknowledge Shamah Iqbal, MD, for pathologic evaluations of the gross and microscopic specimens.