Clinical History
A 70-year-old man with ectropion of the right eyelid and an ulcerated lesion of the right cheek that had not healed for weeks was referred to our department to perform a head-and-neck CT examination. He underwent major surgery 7 and 4 months before at another hospital for zygomatic spinocellular carcinoma.
Imaging Findings
CT revealed a vascularized lesion of the right cheek with infiltrative growth pattern, sized 4cm in its largest transverse diameter, which extended to the soft tissues of the nasal wing and caused erosion of the neighbouring bony structures (i.e. ipsilateral nasal bone, maxillary frontal process, and anterior wall of the right maxillary sinus). The lesion also showed signs of ipsilateral orbital involvement (Fig. 1, 2).
Lymph nodes with short axis under 1cm were present at different levels.
Subsequently, a total body PET-CT and a head-and-neck MRI examinations were performed to complete staging and confirmed CT findings. No intracranial or bone marrow involvement were demonstrated (Fig. 3-5). Biopsy of the right cheek lesion revealed squamous cell carcinoma.
Discussion
Skin cancers are the most common malignant tumours among Caucasians [1]. Ninety-five percent of skin cancer are non-melanoma cancers (NMSC), resulting in one-third as many deaths as melanoma [2]. Approximately 80 percent of NMSC are basal-cell carcinomas (BCC), and 20 percent are squamous-cell carcinomas (SCC) [3]. Unlike BCC, cutaneous SCC can metastasize.
Risk factors include advanced age; male sex; origin from regions of Northern Europe; fair complexion; inability to tan; easy sunburn; fair hair and blue or green eyes; and chronic scars, ulcers, burns, and sinuses condition [1]. Exposure to UV radiation of sunlight seems to be the most important risk factor; other environmental pathogens include ionizing radiation, arsenic, and the products arising from the combustion and distillation of coal, bituminous shales, and petroleum.
Body regions most affected are face, trunk and arms (men), and face and legs (women).
Actinic keratosis is a precancerous lesion which precedes SCC of the skin; other precancerous conditions include bowenoid papulosis and epidermodysplasia verruciformis [3]. The lesions are papules or plaques that tend to be firm, skin-coloured or pink, smooth or hyperkeratotic, and may be ulcerated. Lesions can be itchy or painful, tend not to heal, and may bleed when traumatized [3]. Biopsy is necessary to define the histological type.
Most SCCs are localized to the site of presentation and do not require imaging before removal. However, locally advanced tumours or those fixed to bone should be managed to determine the extent of disease, including signs of perineural spread, lymph node dissemination, bone involvement, and orbital and/or intracranial invasion [4].
Sometimes SCCs may recur. Factors predisposing to disease recurrence are: size (> 2 cm), site (lip and ear), immunosuppression, previous recurrence, depth (>4mm or Clark IV/V), poor differentiation, or perineural invasion [5].
CT and MRI are essential for staging, preoperative and postoperative evaluation, and follow-up. They can reveal involvement of subcutaneous layers, deep facial planes, and underlying muscoloskeletal structures, as well as lymph node dissemination. While extension and bone involvement are better displayed using CT, contrast enhanced MRI is more useful for detecting perineural spread (mostly when eyebrow and infraorbital regions are involved, such as in our case), and to distinguish the lesion from the surrounding soft tissues and inflammatory alterations [6]. PET may also have a role for detecting local or distant disease extent in patients with high risk SCC.
Because of tumour extension our patient underwent enlarged maxillectomy and right orbital exenteration with myocutaneous flap reconstruction.
Differential Diagnosis List
Recurrent infiltrating squamous cell carcinoma of the cheek
Ectropion of the eyelid
Tumour of the orbit
Cancer of the paranasal sinuses
Basal cell carcinoma of the skin
Final Diagnosis
Recurrent infiltrating squamous cell carcinoma of the cheek
