A 98-year-old female presented with a facial lesion that had been present for 7 months. The lesion had progressively increased in size and was associated with pain and intermittent discharge, prompting medical evaluation. She also reported exertional dyspnea, and physical examination revealed bilateral basal fine crackles on chest auscultation. Her past medical history was significant for hypertension and peptic ulcer disease. She had no previous surgical history. Her regular medications included Anti-hypertensive drug. She had no known drug allergies (NKDA). Her family history was unremarkable, with no significant hereditary diseases or similar lesions.

Complete blood count demonstrated a normal white blood cell count (6.7 × 10⁹/L) and platelet count (244 × 10⁹/L). Hemoglobin was 11.2 g/dL with a red blood cell count of 3.40 × 10¹²/L and a hematocrit of 32.2%, consistent with mild normocytic anemia (MCV 94.5 fL, MCH 33.0 pg).Renal function tests showed an elevated blood urea level of 61.3 mg/dL, while serum creatinine was 0.987 mg/dL, indicating preserved renal function despite an isolated rise in urea.Preoperative viral screening was non-reactive for HIV-1/2, hepatitis B surface antigen (HBsAg), and hepatitis C virus (HCV) antibody.

High-resolution CT of the chest demonstrated features of diffuse pulmonary fibrosis, characterized by bilateral predominantly peripheral and basal subpleural reticular opacities with associated architectural distortion and traction bronchiectatic changes, mainly involving the upper lobes. Bilateral honeycombing changes were also noted, more prominent in the lower lobes. No pulmonary nodules, masses, or focal areas of consolidation were identified. There was no pleural effusion or pneumothorax. Diffuse pulmonary fibrosis with imaging features suggestive of a usual interstitial pneumonia (UIP) pattern. No significant mediastinal, hilar, or axillary lymphadenopathy was seen.The heart size and great vessel calibers were within normal limits. Coronary artery calcifications were noted.

Histopathological evaluation of the forehead skin incisional biopsy specimen revealed squamous cell carcinoma, not otherwise specified (SCC NOS). Sections demonstrated downward proliferation of variably sized nests of atypical squamous cells extending from the epidermis into the subcutaneous tissue, reaching the deep margin of the biopsy, with a depth of invasion measuring at least 0.7 cm. The tumor showed irregular infiltrative nests at the periphery, composed of cells with abundant eosinophilic cytoplasm and moderately pleomorphic nuclei with vesicular chromatin and prominent nucleoli. Mitotic activity, keratin formation, and associated neutrophilic inflammatory infiltrate were identified. There was associated solar elastosis and giant cell reaction to keratin material. No evidence of lymphovascular invasion or perineural invasion was identified.

Through an elliptical incision, a wide local excision (WLE) of the right forehead skin lesion was performed. A lateral rotational flap was then created for reconstruction of the defect. Hemostasis was secured, and the wound was closed appropriately.

Histopathological evaluation of the right forehead skin wide local excision specimen revealed squamous cell carcinoma, not otherwise specified (SCC NOS). Sections demonstrated a moderately differentiated (Grade 2) invasive squamous cell carcinoma measuring 2.7 cm in greatest dimension, with a tumor thickness of 0.9 cm and a depth of invasion of 1.1 cm. The tumor showed extension into the subcutaneous fat and skeletal muscle bundles (anatomic level V) and was associated with surface ulceration.Lymphovascular invasion and perineural invasion were identified. The tumor was excised with negative margins, with the closest margin being the deep margin (<0.1 cm), followed by lateral and medial margins at 0.5 cm, inferior margin at 0.5 cm, and superior margin at 0.7 cm.Extensive solar elastosis was present. A large and deep cystic invagination was noted within the tumor, giving the impression of an associated underlying pilar cyst; however, no benign precursor lesion was identified in the examined specimen.Pathological staging: pT3.

The patient tolerated the procedure well with no immediate postoperative complications. The surgical wound was monitored regularly, and the flap remained viable with satisfactory healing. Pain was controlled with appropriate analgesia, and there were no signs of wound infection or dehiscence.The patient was referred for further multidisciplinary evaluation, including consideration of adjuvant therapy due to the presence of high-risk pathological features, particularly lymphovascular invasion, perineural invasion, and deep tumor invasion.Regular clinical follow-up was arranged for surveillance of the surgical site, assessment for local recurrence, and evaluation of regional lymph nodes.