Photo Rounds

Growing cyst on face

A 75-year-old man presented to a family physician (FP) with a 1-year history of a growing cyst on his face. (He had hoped it would go away on its own.) The cyst was getting closer to his eye and there were some red lines running down his cheek, so the patient thought he needed to get it checked out. When the patient pressed on the cyst, he said that some material would come out. The patient’s blood pressure was elevated, as he had run out of his antihypertensive medications.

What’s your diagnosis?


Growing cyst on face

The FP suspected this was more than just a simple cyst, and his differential diagnosis included basal cell carcinoma and squamous cell carcinoma (SCC). The FP advised the patient that a punch biopsy was needed to determine the diagnosis and that it was not possible to just remove the cyst. The patient consented to the biopsy, and the FP performed a 4-mm punch biopsy. (See the Watch & Learn video on “Punch biopsy.”)

The pathology showed an invasive SCC. Note that cutaneous SCCs can appear cystic on presentation. Due to the location and size of the SCC, the patient was referred to Head and Neck Surgery for resection of the tumor and flap repair. The temporal branch of the facial nerve was spared. And, while it appeared that the red lines radiating down the cheek from the tumor were lymphangitic spread, the pathology at the time of the tumor resection did not show this. The surgery achieved clear margins, and the patient recovered well.

On a follow-up visit, the FP performed a total body skin exam to look for other skin cancers and found none. He also counseled the patient on sun avoidance, the consistent use of a hat outdoors, and the use of sunscreen when exposed to the sun.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Karnes J, Usatine R. Squamous cell carcinoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:999-1007.

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