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‘Dragon horn SCC’
  1. Agata Marta Plonczak,
  2. Ramy Aly,
  3. Hrsikesa Sharma and
  4. Anca Breahna
  1. Plastic Surgery, Countess of Chester Hospital, Chester, Cheshire West and Chester, UK
  1. Correspondence to Agata Marta Plonczak; agata.plonczak{at}

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A 50-year-old manual labourer presented with a 3-year history of a progressively enlarging lesion to the lower back. In terms of risk factors, the patient had no significant sun exposure, no previous or family history of skin malignancy and was not immunosuppressed. He did not take any regular medication but he was a smoker.

The patient has Fitzpatrick skin type II. On examination there was an enormous cutaneous horn on the lower back measuring 140×60×55 mm (figures 1–3). Surprisingly, there was no palpable lymphadenopathy.

Figure 1

Gigantic keratotic horn over back—posterior view.

Figure 2

Gigantic keratotic horn over back—left lateral view.

Figure 3

Gigantic keratotic horn over back—right lateral view.

The patient underwent wide local excision of the tumour under general anaesthetic, and the large soft tissue defect created was reconstructed with a split thickness skin graft from his thigh. Histopathological analysis confirmed a well-differentiated cutaneous squamous cell carcinoma with an 8 mm peripheral clearance margin and 7 mm deep margin.

Cutaneous horns are thought to result from underlying benign, premalignant or malignant in 61.1%, 23.2% and 15.7% of cases, respectively.1 Squamous cell carcinoma has been reported in 94% of horns with a malignant base.2

Cutaneous squamous cell carcinoma (cSCC) is the second most common non-melanoma skin cancer (NMSC)/keratinocyte carcinoma,3 and in some studies incidence is approaching that of basal cell carcinoma. In addition, its incidence is increasing both in the USA and in Europe.3 4 Risk factors that predispose to the development of cutaneous squamous cell carcinoma include light skin (Fitzpatrick skin types I–III), age, male sex, exposure to sunlight or other ultraviolet radiation, immunosuppression, human papillomavirus, chronic scarring conditions, familial cancer syndromes and environmental exposures, such as arsenic.

Surgical excision with a predetermined clinical margin is the recommended treatment for the majority of cSCC. For clinically well-defined, low-risk tumours, a margin of 4 mm will achieve histological clearance in over 95% of cases. In high-risk cSCC, the evidence on peripheral margins required is limited, but at least 6 mm should be included in the resection.5 One millimetre histopathological clearance is considered adequate. The overall regional metastatic rate of cSCC in a UK population has been reported at around 5%.6 Patients with high-risk NMSC should be treated by members of a skin cancer multidisciplinary team in secondary care.

We report a rare case of an extremely large well-differentiated SCC that was neglected by a patient living in a developed country with access to free healthcare. This highlights that despite current public skin cancer awareness and rigorous healthcare measures, cases like this can still arise and slip through the net.

Learning points

  • Cutaneous squamous cell carcinoma (cSCC) is the second most common non-melanoma skin cancer. Most cases are diagnosed and treated early before becoming ‘dragon horns’.

  • Despite current public skin cancer awareness and rigorous healthcare measures, SCCs as big as this can still arise and slip through the net.



  • Contributors AMP is the first author, she drafted the first manuscript. RA edited the manuscript and gave feedback with regards to the intellectual content. HS contributed to the plan and design of the manuscript as well as editing it. AB is the consultant who treated the patient who contributed to the idea, design of the manuscript, acquisition of data by obtaining medical photography as well as consent, and she edited the final draft of the manuscript. AMP and AB consented the patient.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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