556 © 2003 European Academy of Dermatology and Venereology CASE REPORT JEADV (2003) 17, 556 – 558 Blackwell Publishing Ltd. An unusual presentation of primary cutaneous squamous cell carcinoma H Baloglu,†* B Dogan‡ Departments of †Pathology and ‡Dermatology, GATA Haydarpasa Teaching Hospital, Kadikoy, Istanbul, Turkey. *Corresponding author, tel./fax +(216)489 4449; E-mail: hbaloglu@superonline.com ABSTRACT The cutaneous squamous cell carcinoma is a malignant epithelial tumour that usually arises from an under- lying precursor skin lesion. We report the case of a 65-year-old woman with multiple de novo squamous cell carcinomas in an unusual presentation. Key words: skin, squamous cell carcinoma, unusual presentation Received: 13 February 2002, accepted 22 May 2002 Introduction The cutaneous squamous cell carcinoma (SCC) is a neoplastic proliferation of the epidermal keratinocytes showing anaplasia, rapid uncontrolled growth, local invasion and metastatic potential. The frequency of SCC of the skin varies in different parts of the world depending mainly on sun exposure and skin type. It is 25 per 100 000 in Australia, and 35.8 per 100 000 in the United Kingdom. The rate for black Americans is much lower, about 3 per 100 000. 1–3 Ageing seems to be another factor for SCC in a large retrospective study showing the mean ages at diagnosis being 68.1 and 72.7 years for men and women, respectively. 4 In the vast majority of cases an underlying precursor skin lesion, mostly actinic damage, has been defined. Primary SCC may also develop de novo without being transformed from an underlying precursor lesion in some instances. The course may stay limited to the initial region or may metastasize to regional lymph nodes and distant sites. We present an unusual presentation of a primary cutaneous SCC with no history of underlying precursor skin lesion. Case report A 65-year-old Caucasian woman was referred to our dermatology clinic (GATA Haydarpasa Teaching Hospital, Kadikoy, Istanbul, Turkey) because of multiple ulcerated skin tumours all over her anterior trunk. She noticed the very first lesion as a red, non-tender papule on her sternum 2 years ago. From that time on, similar new skin lesions appeared all over her anterior trunk only. Initial skin lesions were purplish fragile indurations and /or nodules. They were of different sizes, ranging from 0.5 cm to 3 cm in diameter. At presentation, in addition to newly developing lesions, older ones had become larger, ulcerated, some infected, and some vegetating and arborized with each other (fig. 1a). Interestingly, there was no skin involvement anywhere else other than the anterior trunk (fig. 1b). Weakness and the skin lesions on her anterior trunk were bleeding continuous and were ulcerated and therefore needed immediate medical care. There was no history of psoralen + ultraviolet A treatment and /or chemotherapy for any other disorder. Fine needle aspiration biopsy was the initial approach for microscopic diagnosis of the skin lesions. Cyto- logical examination revealed conspicuous anaplastic squam- ous cells evenly spread or in small irregular multilayered groups mimicking squamous lining (fig. 2a). Core samples were selected among debrided necrotic and infected skin lesions and routinely processed and evaluated by light microscopy to confirm cytological diagnosis. Moderately differentiated SCC was seen (fig. 2b). Imaging investigations for staging revealed no additional lesions, and no nodal involvement either (T 2 N 0 M 0 , stage II/American Joint Committee on Cancer 1997). Haematological profiles showed thrombocytopenia and anaemia because of long-term bleeding in the skin lesions. The patient was able to be treated by chemotherapy in the department of oncology after intensive supporting therapy, including whole blood and /or thrombocyte suspensions