An 86-year-old woman, a nursing home resident presented to a dermatology consultation with an ulcerated/necrotic lesion on the inferior lip and right labial commissure, extending into the cervical region, with purulent discharge (Fig. 1) and hemilateral facial edema (right side), alongside multiple lymphadenopathies.

Figure 1: Tumoral lesion of the inferior lip, extending into the cervical region, with purulent discharge 

The cutaneous biopsy confirmed that it was a poor differentiated squamous cell carcinoma (SCC) and the staging by computed tomography (CT) scan (Fig. 2) revealed a carcinomatous lesion with a necrotic center and skin fistulation, on the right side of the inferior lip, that cover all the right hemiface, submandibular and sublingual areas, from jaw angle to the carotid space.

Figure 2: Skull CT scan - sagittal plane: tumor masses 

Also showed laryngeal invasion and jaw fracture. Necrotic-cystic lymph nodes were also observed in the carotid, cervical and supraclavicular chains, bilaterally.

The patient was referred to palliative care and passed away two weeks later.

The cutaneous SCC is a malignant tumor,^1,2 usually noninvasive and with high cure rates, what highlights the exceptional nature of this case.^3,4

Approximately 3% to 5% of cutaneous SCC cases metastasize to locoregional or distant lymph nodes.

Larger primary lesions and smaller cell divisions, as the location in a sun-exposed area and the immunocompromised state of the patient are associated with increased rates of tumor metastasis and recurrence.

In addition to this, there are several risk factors associated with metastases and recurrence: the size of the lesion (greater than 2 cm in greatest dimension), the thickness of the lesion (greater than 2 mm), the high-risk anatomic location (lip), and the poor differentiation confirmed by the biopsy.

With this case report, we intend to reinforce the importance of early referral of patients, regardless of their general physical or cognitive status.

Although the patient was not responsive, timely recognition, diagnosis and treatment could have influenced the outcome, giving her a dignified and serene end of life.