A 78-Year-Old Tennis Player With a Growth on His Scalp

Carl H. Manstein, MD, MBA; Samuel Max Manstein

Disclosures

July 20, 2016

Correct Answer: B. Complete excision and either flap or skin graft reconstruction

The size of the lesion is too large (2 cm in diameter) to allow for primary closure. Secondary healing and granulation might be indicated for an infirm or institutionalized patient. As his history indicates, this man is still an active athlete. 5-fluorouracil is only indicated for very superficial basal cell cancers. Radiation therapy is a possibility but should not be indicated as a primary treatment because it would require daily visits for 4-5 weeks and would interrupt his activities of living, whereas with surgical excision the patient would be back at full activity in 2-3 weeks. If he has recurrence, radiation therapy might then be considered.

Discussion

Keratinocyte carcinomas (ie, basal cell and squamous cell) are the most prevalent malignancies in the United States, and their incidence is rising.[4] The main risk factor for developing basal cell carcinoma is exposure to ultraviolet radiation, particularly high-dose exposure at a young age.[5] Sweating because of physical exercise may contribute to ultraviolet-related skin damage, as it increases the individual photosensitivity of the skin.[6] The patient in this case study has been an active tennis player for over 60 years, so he most certainly has received a large dose of ultraviolet radiation exposure, increasing his risk for basal cell carcinoma.[7,8,9]

The treatment of this patient might generate the most controversy. We advocate surgical excision for a definitive histopathologic diagnosis of the specific tumor type and to identify any residual cancer at the resection borders. The value of skin grafting versus flap reconstruction, however, is an important discussion.[10] Primary radiation has its place in the treatment of basal cell cancers,[11,12,13] but we think that this patient's active lifestyle would preclude its use. Finally, topical 5-fluorouracil is only indicated in very superficial basal cell cancers and would not have been appropriate for this patient.[14]

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