A Non- Nephrology NursiNg JourNal
Case Study
A Non-Healing Lesion on the Anterior Chest
of a Patient Receiving Hemodialysis: A Case Study
Matthew David Wynne, MBBS, iBSc, MRCP, and Manu Shah, MD, FRCP
An 82-year-old man receiving hemodialysis was
referred to Dermatology with a non-healing lesion on his
right anterior chest wall. This arose at the precise site of his
previous tunnelled hemodialysis catheter, which had been
removed 18 months earlier. He reported discussing his
concerns with health care professionals during this time,
but the cause was considered to be slow healing at the
wound site. This led to a delay in referral.
His past medical history included type 2 diabetes mel-
litus, ischaemic nephropathy, atrial fibrillation, hyperten-
sion, and left ventricular hypertrophy. He had also been
treated for multiple basal cell carcinomas (BCCs) on the
upper lip, left shoulder, left forearm, left lower back, and
the left upper anterior chest. He had worked outdoors
doing manual labor for most of his life.
Examination of the chest revealed a 2x3 cm ulcerated
nodule, with rolled erythematous edges and indistinct clin-
ical margins (see Figures 1 and 2). A diagnostic punch
biopsy was performed; histopathological analysis demon-
strated BCC. Due to the size of the lesion and its proximity
to the patient’s current hemodialysis catheter, he was
referred to Plastic Surgery for complete excision.
Basal Cell Carcinoma
Basal cell carcinoma is the most common type of skin
cancer worldwide (Christensen et al., 2019). The exact inci-
dence is unknown because there is no requirement to
report BCCs to cancer registries. However, it is estimated
that BCCs make up 80% of the 5.4 million non-melanoma
skin cancers (NMSCs) diagnosed annually in the United
States (American Cancer Society, 2021).
Due to immunosuppression, the risk of developing a
BCC is increased in patients who have received a kidney
transplant (Krynitz et al., 2016). This increased risk may be
Matthew David Wynne, MBBS, iBSc, MRCP, is a ST3 Dermatology
Registrar, Burnley General Teaching Hospital, Burnley, East Lancashire
Hospitals NHS Trust, Burmley, United Kingdom.
Manu Shah, MD, FRCP, is a Consultant Dermatologist, Burnley General
Teaching Hospital, Burnley, East Lancashire Hospitals NHS Trust,
Burmley, United Kingdom.
Nephrology Nursing Journal May-June 2022 Vol. 49, No. 3
Copyright 2022 American Nephrology Nurses Association
Wynne, M.D., & Shah, M. (2022). A non-healing lesion on the
anterior chest of a patient receiving hemodialysis: A case
study. Nephrology Nursing Journal, 49(3), 277-278, 299.
https://doi.org/10.37526/1526-744X.2022.49.3.277
Basal cell carcinoma is the most common type of skin can-
cer, and patients receiving hemodialysis are at increased
risk of developing them. This article describes a case of a
patient with a basal cell carcinoma in which the diagnosis
was delayed due to the lesion masquerading as granula-
tion tissue at the site of a previous tunnelled hemodialysis
catheter. Early detection of basal cell carcinomas is impor-
tant because delayed detection increases the risk of local
invasion and the requirement for more complex surgical
management.
Key Words:
Basal cell carcinoma, wound, hemodialysis.
comparable in patients receiving dialysis but without a his-
tory of kidney transplant (Sułowicz et al., 2017). While the
reason for this is unclear, it may be due to the increased
average age of patients starting dialysis, with age being an
independent risk factor for BCC development (Hallaji et
al., 2011; Lehmann et al., 2012). Other risk factors for devel-
The Case Study department of the Nephrology Nursing Journal
invites nephrology nurses of all levels and subspecialties to share
their clinical experience with their colleagues. Practitioners and
educators are encouraged to submit case studies that address
patient-related nursing care and solutions to situations
encountered in the care of a patient with renal disease and/or in
performing extracorporeal therapies. Address correspondence
to: Jean Colaneri, Department Editor, through the ANNA National
Office; East Holly Avenue/Box 56; Pitman, NJ 08071-0056; (856)
256-2300, or by emailing her at colanerij@mail.amc.edu.
The opinions and assertions contained herein are the private
views of the contributors and do not necessarily reflect the views
of the American Nephrology Nurses Association.
277
Case Study
Figure 1
A Crusted Lesion on the Right Anterior Chest
at the Exit Site of a Previous Tunnelled
Dialysis Catheter
oping BCCs include ultraviolet (UV) light exposure from
both the sun and sunbeds, working outdoors, repeated
episodes of sunburn, Fitzpatrick skin type 1, and exposure
to ionising radiation (Bauer et al., 2011; Khalesi et al., 2013;
Mathews et al., 2013).
BCCs typically present as slow-growing, non-healing
nodules in sun-exposed sites. Nodular BCCs have classic
clinical features, including pearly rolled edges, central
ulceration, and overlying blood vessels, known as telang-
iectasia (Dourmishev et al., 2013). BCCs often have indis-
tinct clinical margins, with sub-clinical extension, meaning
their borders extend beyond what is visible macroscopical-
ly (Toosi et al., 2017).
Dermoscopic evaluation and use of the skin ‘stretch test’
can aid in clearer approximation of their borders (Shalom
et al., 2011). As described by Shalom and colleagues (2011),
the technique of stretching the skin containing the tumor is
“based on the fact that the microvessels within a BCC are
distinctly different from those in the surrounding skin and
represent a tumor microcirculation” (p. 72). This microcir-
culation is emptied by stretching, allowing the distinct
pearly color, which represents the tumor’s stoma, to be
more visible, and therefore, aiding in delineating the
tumor’s clinical margins (Shalom et al., 2011).
The differential diagnoses in this case included squa-
mous cell carcinoma and granulation tissue because the
278
Figure 2
Closer Inspection Reveals a Nodule with Rolled
Edges, Central Ulceration, Overlying Crust
and Indistinct Margins
lesion arose from a chronic wound. The development of a
nodule, irregular thickening, bleeding, or pain in chronic
wounds should raise suspicion of an evolving malignancy,
especially in the context of delayed wound healing. In
these circumstances or when the diagnosis is unclear, a
skin biopsy is important to detect malignant change.
Early Detection
Early detection is important. While metastatic BCC is
rare, delayed detection increases the risk of local invasion
and the requirement for more complex surgical manage-
ment.
Conclusion
Nephrology nurses provide continuity of care for and
routinely build rapport with patients receiving hemodialy-
sis. Given the incidence of BCCs in general and the
increased risk for these patients, it is likely that nephrology
nurses will encounter patients with BCCs and other types
of skin cancer. Nephrology nurses must be aware of the
potential for BCCs because they are well-positioned to
detect BCCs presenting as abnormal growths near
hemodialysis access sites.
continued on page 299
Nephrology Nursing Journal May-June 2022 Vol. 49, No. 3
Case Study
continued from page 278
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