An elderly woman presented with a hyperkeratotic nodule over the vertex of scalp for few months
Adrian KC Cheng

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Clinical history:

An 87-year-old woman presented with an enlarging mass over the vertex of her scalp for a few months. Examination showed a 4x4cm hyperkeratotic nodule. A fleshy friable base with contact bleeding was revealed after crust removal.

What is the diagnosis?

Answer:
B. Squamous cell carcinoma

The diagnosis is B. Squamous cell carcinoma (SCC). This elderly woman presented with a rapidly enlarging hyperkeratotic scalp nodule with a friable bleeding base after crust removal, which is highly suspicious for cutaneous SCC. The scalp, particularly the vertex, is a common site for SCC in elderly patients due to chronic cumulative ultraviolet exposure. Cutaneous squamous cell carcinoma is the second most common non-melanoma skin cancer and typically occurs in elderly individuals on chronically sun-exposed areas such as the scalp, face, ears, and dorsal hands. Clinically, SCC may present as a hyperkeratotic papule, plaque, or nodule with crusting, ulceration, friability, and contact bleeding. Rapid enlargement and tenderness may also occur. Histopathological examination is required for definitive diagnosis. Management depends on tumour size, depth, and risk factors, and may include surgical excision, Mohs micrographic surgery, radiotherapy, or other modalities. Early diagnosis is important because SCC carries a risk of local destruction and metastasis.

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The slide and the question was prepared by:

Dr. Adrian KC Cheng, ^{MBBS(HK), MRCP(UK), MSc GEOR (CUHK), FHKCP, FHKAM (Medicine)}

Specialist in Dermatology & Venereology;

Associate Consultant,

Division of Dermatology, Department of Medicine, Queen Mary Hospital, Hong Kong SAR