Squamous cell carcinoma — SCE Dermatology MCQ

Correct answer: C — Suspected cancer pathway referral for possible SCC

The correct answer is C, suspected cancer pathway referral for possible SCC. This lesion has the classic features of cutaneous squamous cell carcinoma: a rapidly enlarging (10 weeks), tender, crusted, indurated nodule on a chronically sun-damaged site (dorsal hand) that bleeds on minor trauma. NICE NG12 advises that a suspected cancer pathway referral should be considered for any skin lesion raising suspicion of SCC, reflecting its faster growth and metastatic potential compared with BCC. His renal transplant confers long-term immunosuppression, which markedly increases both the incidence and aggressiveness of SCC, lowering the threshold for urgent referral. Induration at the base is a specific clinical sign of dermal invasion and is a recognised discriminator favouring SCC over a benign keratosis or BCC. Why the other options are wrong: E. Routine referral because it may be BCC: BCCs typically grow slowly over months, are rarely tender, and rarely bleed spontaneously; NICE reserves routine referral for suspected BCC, which does not match this rapidly evolving, tender, indurated lesion. A. Reassurance with review after emollients: Emollients treat dry skin, not a growing malignant lesion, and delaying assessment risks disease progression and metastasis in an immunosuppressed patient. D. Topical antifungal therapy before referral: There are no features suggesting fungal infection (no annular scale, no response expected), and empirical antifungal use would simply delay cancer diagnosis. B. Cosmetic curettage without histology: Destructive treatment without tissue diagnosis risks incomplete excision of an invasive tumour and loses staging information needed to guide further management. Key point: A tender, indurated, rapidly growing crusted nodule on sun-damaged skin in an immunosuppressed patient mandates a suspected cancer pathway referral for SCC, not routine BCC pathways or destructive treatment without histology.

Reference: NICE guideline NG12, Suspected cancer: recognition and referral (2015, updated 2021), section on skin cancer, https://www.nice.org.uk/guidance/ng12