What's the Take Home?

A 76-Year-Old Man with a Lesion of the Right Ear

Ronald N. Rubin, MD
Volume 66 - Issue 2 - February 2026

  • Correct Answer: A. There is no significant difference in mortality outcome when standard excision or Mohs procedure are available treatments.

    Discussion. The differential diagnosis should include some form of skin carcinoma, the most common of which are basal cell carcinoma and squamous cell carcinoma. Indeed, this lesion turned out to be a squamous cell cancer (SCC).

    The demographics and epidemiology of cutaneous SCC generally involve light skin, an older patient, and high ultraviolet (UV) exposure. These characteristics are significant multiplier effects on the incidence of skin SCC.

    Skin cancer is the most frequently diagnosed cancer in the United States and world. While significantly less common than basal cell carcinoma, SCC is far more common than melanoma and accounts for roughly 20% of skin cancers.1 Age is an important risk factor, with persons older than 75 years of age having 5-10 times more SCC than persons younger than 55.1 Men far outnumber women in incidence, likely due to more lifetime sun exposure. This melds with the third risk factor: UV radiation exposure with its subsequent DNA damage. Generally, this is from a lifetime of sun exposure and lifestyle habits such as indoor tanning, which have made that niche another higher risk population. The relationship of enhanced risk and numbers in people with lighter colored hair and light eyes has long been known.1 

    Additionally, a substantial risk factor becoming ever more frequent is innate acquired and iatrogenic immunosuppression such as with T cell disorders, chronic lymphatic leukemia or lymphomas, or the patient taking an immunosuppressive medication such as rituximab. These patients also have a high multiplier risk for SCC almost as if natural immunity has a protective effect against SCC and when this immunity is impaired, these cancers can and do increase in its absence.1,2

    The clinical presentation is rather straightforward. Lesions are found with some combination of scaly, erythematous, easy bleeding with poor, incomplete healing. Nodularity and heaping up at the margins are two clues that point to SCC rather than basal cell carcinoma. However, there is significant overlap between the appearances of basal cell and SCC. The former is far more common and far less difficult in both management and prognosis such that often a small punch biopsy is needed to clarify which is present. The more sun exposure the higher the incidence so face, nose, ears, neck and temples are the heartland of incidence sites.

    Diagnosis and staging. Once a patient has noticed a suspicious lesion on the skin surface that persists and will not totally heal, the next phase in evaluation is two-fold: obtaining a tissue diagnosis and pathological/clinical staging of the lesion. Some form of biopsy will be occurring be it by surgical wedge excision or Mohs type surgery. The biopsy will give histologic evidence for SCC (in contrast to basal cell carcinoma, a markedly less dangerous lesion with an extremely low risk for metastasis and mortality and thus needing far less of a surgical procedure). Low risk characteristics are size less than 2 cm, good differentiation, depth less than 2 mm penetration into subcutaneous fat, and absence of perineural invasion. High risk characteristics are size greater than 2 cm, poorly differentiated, presence of perineural invasion, and depth of penetration more than 2 mm.1,3 Additional high-risk characteristics include sites of lesion with cancers arising in a scar or on temple, ear, and lip being higher risk. These characteristics are combined into a schema, which vary somewhat by specialty society into a formula for overall risk categories of low risk, high risk and very high risk with each having its proper therapy proscriptions.1,3

    Surgery with curative intent is the core management of cutaneous SCC with cure rates in the 95% range.1,4 Therapeutics for cutaneous SCC requires application of the following principles. First is where on the spectrum of metastasis/mortality risk is the primary tumor. Second is the current listing of effective procedures available to address the skin primary. These include curettage and electrodessication, which is essentially always an outpatient office procedure not requiring general anesthesia or detailed pathological examination (e.g. margins) or the far more extensive Mohs microscopic surgery often requiring more complex anesthesia, an OR setting, and so called PDEMA or peripheral and deep exhaustive pathological margin assessment. Standard surgical excision also can address most SCC. Radiation therapy is effective in SCC of the skin but reserved for patients in whom for whatever reason surgery is contraindicated.

    The third principle is the demographic of the patient as to location and cosmesis of the procedures. A low or intermediate risk lesion of the trunk, extremity or neck in a 60-year-old man might easily and quickly be cured by a standard cancer operation by office surgical resection, whereas even a smaller, low-risk lesion of the facial area of a younger patient would be better served by the more expensive and complex anesthesia requiring Mohs technique. Considering the cure rates of surgical excision and Mohs are so similar,5 I was greatly surprised by the cost-differences between the two approaches. In some low-risk cases, either curettage and electrodessication or a standard local excision has cure rates approaching or surpassing 95%.1,4  In localized but high risk and even very high-risk cases, Mohs surgery has excellent results, with rate of local recurrence, nodal metastasis, and/or disease specific death rates on 1.2-4.1%.1,4

    An important new treatment modality for those few cases that reach systemic metastatic stage involves the monoclonal antibody cemiplimab, which is a programmed death (PD-1) targeting antibody recently approved for such cases and has a robust response rate of 47% with an equally robust median duration of response of 41 months.6

    The overall survival in cutaneous SCC is excellent. Nodal metastasis is reported as 1.9-5.2% and disease specific mortality at 1.5-3.4%1,4 There is a risk stratification in the overall skin cancer population such that the nodal metastasis and mortality will be higher in higher risk subpopulations. A special consideration, as previously alluded, is the issue of patients with immunosuppression. This patient population becoming ever more common as the population ages and immune suppressive medications become ever more ubiquitous in general medicine. A data point amplifying this issue is a reported metastasis and local recurrence rate of 6-15% in these patients compared to the 1.9-5.2% rates in patients without immunosuppression.7

    Patient follow-up. The patient chose to consult an otolaryngologist as the lesion was on the ear. An office procedure of punch biopsy was non-diagnostic. The lesion was on the anti-tragus area, a technically and cosmetically difficult area so the patient was taken to surgery under general anesthesia where a 1.5 cm lesion was surgically excised. A small skin graft from the neck was used to close the wound. Histology was moderately differentiated SCC with no high-risk histological characteristics and a good negative margin. Proper healing required a compressive bandage for 2 weeks to allow for grafting. Healing was otherwise uneventful and follow up at 6-month intervals were performed out to the 2-year interval, which is the interval time lapse of highest recurrence risk. He is 7 years out with no evidence of recurrence although he has had several new basal cell carcinomas removed from the shoulder, arm, and leg since the ear surgery. He is now very scrupulous with his sun exposure including actual ear covering. Of note, the so called "volcano lesion" is an uncommon variant of SCC of the skin and was not always considered malignant either histologically or by its relatively indolent and waxing/waning nature. It is now generally considered a low-grade SCC.8

    What’s the Take Home? Nonmelanoma skin cancers are the most common cancers in the United States. Cutaneous SCC comprises about 20% of these skin cancers with basal cell tumors being far more common and melanomas far less. Key risk factors include age, genetic factors of light hair color, fair skin and light color eyes, degree of exposure to UV radiation mainly due to sun exposures but also due to indoor tanning situations now ever more common, and any form of immunosuppression be acquired (e.g. CLL, lymphomas), genetic defects in T cell function or iatrogenic as with the use of the new anti-inflammatory drugs. The lesions present on the skin as erythematous, scaling areas which bleed easily. Often skin biopsy and removal are performed simultaneously and is curative. A schema of risk stratification utilizes histological (e.g. depth, nature of invasion, degree of tumor differentiation), size with 2 cm and 4 cm being key diameters and location (e.g. lip, temples, and ear having increased risk) to guide therapeutic interventions and prognosis. For low risk, simple curettage and electrodessication is curative. For high risk and very high-risk cases a true local excision with adequate margins is required using either surgical excision or Mohs micrographic surgery depending upon the location, site involved technically, and cosmetic issues encountered. The roles of adjuvant radiation and the newer PD-1 check point inhibitor monoclonal antibodies are potentially effective, more available and useful in advanced cases. Prognosis is excellent overall with survival rates in the 95% range but are somewhat lower in high-risk patients. The age demographic and immunosuppressive risk factors in SCC of the skin clearly indicate these already common tumors will become even more so going forward.

    AUTHOR
    Ronald N. Rubin MD1,2

    AFFILIATIONS
    1Lewis Katz School of Medicine at Temple University, Philadelphia, PA
    2Department of Medicine, Temple University Hospital, Philadelphia, PA

    CITATION
    Rubin RN. A 76-year-old man with a lesion of the right ear. Consultant. 2026;66(2):DOI:

    DISCLOSURES
    The author reports no relevant financial relationships.

    CORRESPONDENCE:
    Ronald N. Rubin, MD, Temple University Hospital, 3401 N. Broad Street, Philadelphia, PA 19140 (blooddocrnr@yahoo.com)

    References

    1. Wysong A. Squamous cell carcinoma of the skin. N Engl J Med. 2023;388:2362-
    2. Clayman GI, Lee JJ, Holsinger FC, et al. Mortality risk from squamous cell skin cancer. J Clin Oncol. 2005;23:759-765.
    3. Brougham ND, Dennett ER, Cameron R, et al. The incidence of metastasis from cutaneous squamous cell carcinoma and the impact of its risk factors. J Surg Oncol. 2012;106:811-815.
    4. Lansbury L, Bath-Hextall F, Perkins W, Stanton W, Leonardi-Bee J. Interventions for non-metastatic squamous cell carcinoma of the skin: systematic review and pooled analysis of observational studies. BMJ. 2013;347:f6153.
    5. Patel PV, Pixley JN, Dibble HS, et al. Recommendations for cost-conscious treatment of basal cell carcinoma. Dermatol Ther. 2023;13:1959-1971.
    6. Migden MR, Rischin D, Schultz CD, et al. PD-1 blockade with cemiplimab in advanced cutaneous squamous cell carcinoma. N Engl J Med. 2018;379:341-351.
    7. Rischin D, Porceddu S, Day DP, et al. Adjuvant cemiplimab or placebo in high-risk cutaneous squamous cell carcinoma. N Engl J Med. 2025;393:774-785.
    8. Weedon DD, Malo J, Brooks D, Williamson R. Squamous cell carcinoma arising in keratoacanthoma: a neglected phenomenon in the elderly. Am J Dermatopathol. 2010;32(5):423-426. doi:10.1097/DAD.0b013e3181c4340a

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