Squamous Cell Carcinoma In Situ

Patient Case Study: Jose Doe’s Journey With Squamous Cell Carcinoma In Situ

By: Dr. Jenneffer Pulapaka, DPM
DipABLM, CWSP®, DipABMSP, FACCWS, PCWC, retd. AACFAS
Medical Director
DeLand Foot and Leg Center
Podiatric Lifestyle Medicine and Wound Care Management
AAWC BOD

Background

At the DeLand Foot and Leg Center, we treat patients with complex medical histories, such as Jose Doe. His journey is particularly challenging as it involves chronic conditions like diabetes, a below-knee amputation, and the fight against squamous cell carcinoma in situ. Jose’s case is a prime example of the intricate relationship between multiple health issues and underscores the importance of tailoring treatment plans to each individual’s unique circumstances.

Patient Presentation

Jose, a 67-year-old male, came to us with a significant medical history consisting of diabetes, peripheral vascular disease, and an above-knee amputation. He presented with a plantar lesion that had not improved despite being previously treated as a wart by another care provider. Given the lesion’s persistence for over three months and lack of response to treatment, a biopsy was performed during his initial visit. His condition is further complicated by chronic arterial insufficiency that necessitates stents and obesity.

Clinical Observations

Shave biopsies of the right foot’s lesion, measuring 2.1 cm wide x 1.4 cm long x 0.3 cm elevated, revealed a diagnosis of squamous cell carcinoma in situ (Bowen’s Disease). The location of the lesion on the midfoot plantar surface with an expanding margin on the lateral side is troublesome because this is the patient’s right foot, which is his only weight-bearing foot as a result of the above-knee amputation (AKA).

Challenges and Treatment Strategies

Jose’s care required a multifaceted approach involving collaboration with an interdisciplinary team. Consultations with dermatology for close lesion monitoring and potential surgical intervention are key parts of the treatment strategy. The presence of diabetes and its impact on limb health rendered surgical options more complex due to the associated impaired healing. Vitamin D3 supplementation was introduced as a strategic component to improve skin health and immune response potentially.

A Multidisciplinary Approach to Care

Effective management for Jose’s skin cancer within the context of diabetes demanded a comprehensive care strategy including:

– Monitoring Lesion and Vascular Health: Ensuring adequate blood circulation in the affected leg while maintaining foot health.

Grafting and Negative Pressure Wound Therapy (NPWT): If surgical excision is required, the recommendation is to apply Kerecis Shield and NPWT post-surgically. This Kerecis fish skin graft is used successfully to treat chronic diabetic wounds. NPWT applies sub-atmospheric pressure to a wound dressing system, which creates positive pressure on the wound’s surface. This helps reduce inflammatory exudate and promote granulation tissue, which can help optimize wound healing.

– Lifestyle Adjustments: Advocating exercise, nutritional support, and culinary medicine to aid in weight loss.

– Continuous Follow-Up: ABI screenings indicated significant arteriosclerosis with a MAC Score= 4, necessitating evaluation through Color Arterial Doppler imaging for Small Artery Disease, alongside regular dermatology follow-ups in anticipation of potential Moh’s surgical excision.

Importance of Adherence and Lifestyle Changes

Lifestyle modifications cannot be overstated in crafting Jose’s treatment plan. Encouraging adherence to dietary, activity, and medication regimens is crucial for achieving the best possible health outcomes.

Continuous Follow-Up

The patient’s ABI screenings noted significant arteriosclerosis with a MAC score of 4, which requires further evaluation via Color Arterial Doppler imaging to evaluate for Small Artery Disease and regular dermatology consultations preparing for a possible Moh’s surgical excision. All these elements play a vital role in Jose’s treatment trajectory.

Looking to the Future

Our focus extends beyond just treating the squamous cell carcinoma in situ. Considering his confluence of medical issues, we are committed to the long-term management of Jose’s overall healthcare. The subsequent follow-up in the summer of 2024 will be essential in assessing his progress and adapting his care plan based on the interdisciplinary team’s feedback.

Conclusion

Jose Doe’s situation reinforces the significance of biopsying non-healing wounds if they have been persistent for over three months, particularly when they are not amenable to treatments. His case highlights the necessity for personalized care plans and continuous management of complex conditions—our team endeavors to enhance our patients’ overall quality of life through disease management and preventive measures. Vigilance, cooperation, and communication among different specialties are crucial in addressing multifaceted health challenges.

References

– Tokez S, Wakkee M, Louwman M, Noels E, Nijsten T, Hollestein L. Assessment of Cutaneous Squamous Cell Carcinoma (cSCC) In situ Incidence and the Risk of Developing Invasive cSCC in Patients With Prior cSCC In situ vs the General Population in the Netherlands, 1989-2017. JAMA Dermatol. 2020;156(9):973-981. doi: 10.1001/jamadermatol.2020.1988. PMID: 32609322; PMCID: PMC7330830.

– Palaniappan V, Karthikeyan K. Bowen’s Disease. Indian Dermatol Online J. 2022;13(2):177-189. doi: 10.4103/idoj.idoj_257_21. PMID: 35287414; PMCID: PMC8917478.

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