Because the American Joint Committee on Cancer’s (AJCC) staging system guidelines are based on pathology alone, there is controversy surrounding this staging and how accurate it is at predicting mortality and morbidity in patients diagnosed with primary cutaneous melanoma.

We discuss a case of a male patient in his late 70s’ who presented with an asymptomatic rash involving the back and the right knee that initially developed as pink patches, progressed into plaques, and subsequently rapidly evolved into a tumor involving the right knee that was confirmed as blastic plasmacytoid dendritic cell neoplasm on skin biopsy and was accompanied by bone marrow involvement. Upon initiation of first line tagraxofusp-erzs therapy, the patient did not achieve improvement.

This patient’s tumor successfully responded to hedgehog inhibitor allowing surgical excision with clear margins. The orbit was saved in a patient who otherwise would have required complete orbital exenteration.

As many as 31% of squamous cell carcinoma in situ (SCCis) may have a component of invasive SCC that is missed on initial histology due to sampling bias. This case reminds us that sampling bias can occur during biopsy.

Standard of care for squamous cell carcinoma (SCC) is usually surgical, with either excision or Mohs micrographic surgery. However, surgery may not be ideal for elderly patients with numerous lesions, who are poor surgical candidates or who refuse surgery. 

We report the first case of basal cell carcinoma skin cancer arising in the nasal vestibule. The lesion was treated with Mohs micrographic surgery and required three stages to obtain histological clearance. Given the location of the tumor, Mohs surgery was chosen due to the procedure’s effectiveness for achieving the highest cure rate with the lowest incidence of tumor recurrence and for preserving as much adjacent healthy tissue as possible.