A Mass on the Nasal Dorsum

An elderly manwith a history of multiple skin cancers of the face presented with a 4-month history of a mass on the nasal dorsum. Findings from a biopsy of the lesion performed at an outside facilitywereconsistentwithsquamouscell carcinoma(SCC).Threeyears prior, the patient underwent 2 excisional biopsies of a mass at the same location showing infiltratingmoderately differentiated squamous cell carcinoma with acantholytic and pseudoglandular features. The lesion extended into the papillary dermis at the base of the excision. Therewas no endolymphatic or perineural invasion. A third excision performed later failed to demonstrate any disease. The patient’s other medical problems included diabetesmellitus, coronaryarterydisease,andemphysema.Findings fromaphysical examination were significant for a 3 × 2-cm ulcerative, nodular massof thenasal dorsum(Figure, A). Therewasnopalpable lymphadenopathy in theneck.Computed tomographic imagesof thehead andneck revealeda2.6 × 1.7-cmenhancingmass infiltrating thenasal dorsumwith possible involvement of the anterior nasal septum (Figure, B). The patient underwent an en bloc excision with negativemargins. Multiple areas of necrosis and cutaneous ulcerationwere evident. The tumor consistedof nests, trabeculae, and infiltrating rays of mitotically active cells. Some cells showed foamy, clear cytoplasm,while otherswere basophilic to amphophilic (Figure, C). Extensiveangiolymphatic andperineural invasionwaspresent (Figure, D). Immunohistochemical staining was positive for P63 (nuclear) and EMA and focally positive for CAM 5.2 and CK-7. Staining for HMB-45,CD10, chromogranin-A, S100, andVimentinwasnegative. What is your diagnosis? A B