Chief

1
Chiefs Conference

• Mona Massoud, MD
• 2/28/13

2
Case Presentation

• Cc Open area on the bottom of my Right Foot

3
HPI

• 53 yo AAM w/PMH of HTN presents to Grady Derm
  Clinic with a lesion on the sole of his foot
  since July. Reports drainage and foul smelling
  odor. He was seen by a podiatrist 2 months ago
  which excised the lesion for presumptive
  diagnosis of planter wart. Since the excision
  the area has not healed and it has been
  increasing in size. Also reports when bears
  weight on his foot. Denies hx of DM, trauma,
  insect bite, travelling or camping.

4

• PMH hypertension
• Surgical Hx none
• Allergies NKA
• Medications HCTZ 25 mg PO daily
• Social Hx Sales representative, married, has 3
  children. Smokes ½ PPD x 10 yrs. Drinks
  occasionally. Denies hx drug use
• FH mother father HTN. No FH of CA

5
ROS

• () localized pain, yellowish discharge and
  offensive smell.
• (-) rash, joint pain or swelling, fever/chills,
  weakness, tingling or numbness of LE. Other ROS
  were neg.

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PE

• General AO x 3, NAD. Limping gait
• HEENT, Chest, CVS and Abdominal WNL
• Extremities
• 6x5 cm cauliflower exophytic lesion over the
  dorsal of extending to the lateral aspect of Rt
  foot, yellowish in color w/ areas of superficial
  vascularization and keratinization. Surrounding
  hyperpigmentation.
• Foul smelling odor
• Soft to firm w/mild tenderness to palpation
• motor strength 5/5, dosalis pedis and posterior
  tibial present, DTR 2, full ROM.

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pic
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pic
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Differential Diagnosis?

• Diagnosis ???

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Differential Diagnosis

• Planter Wart
• SCC
• BCC
• Vascular Ulcer
• Kaposi Sarcoma
• Malignant melanoma
• Pyogenic granuloma
• Sarcoma

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Contd DD

• Hemangioma
• Radiation Dermatitis
• Decubitus ulcer
• Keloid
• Dermatofibroma

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• Further Qs
• Hx of STDs?
• Hx of chemical exposure?

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Pathology Report

• Verrucous Carcinoma

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Verrucous Carcinoma (VC)
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Verrucous Carcinoma

• Verrucous carcinoma is a locally aggressive,
  clinically exophytic, low-grade, slow-growing,
  well-differentiated squamous cell carcinoma with
  minimal metastatic potential.
• Verrucous carcinoma, also known as epithelioma
  cuniculatum

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Clinical presentation

• More common among middle-aged and older men.
• Most tumors have been treated as recalcitrant
  warts or corns for some time.
• Location most commonly on the sole of the foot,
  but also can occur in web spaces of the toe and
  on the toes, leg, and knee.
• Other locations oral cavity, larynx, genitalia,
  skin, and esophagus.

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Contd

• Foul-smelling keratogenous material may be
  excreted through multiple sinus openings.
• Develops at sites of chronic irritation and
  inflammation.
• Enlarges locally destructive and can penetrate
  deeply into the skin, fascia, and even bone, but
  it has a low metastatic potential.

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Subtypes

• Epithelioma Cuniculatum foot
• Giant condyloma of Buschke genitals
• Subungal keratoacanthoma Immunosuppression or
  SLE
• Grottons carcinoid papillomatosis

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Oral VC

• It is often seen in those who chew tobacco or use
  snuff orally, so much so that it is sometimes
  referred to as "Snuff dipper's cancer."
• Higher risk of a second oral squamous cell
  carcinoma, for which the prognosis is worse.

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Investigations

• CT or MRI may be used to determine the exact
  location and extent of the verrucous carcinoma
  for preoperative staging and surgical planning.

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Treatment

• Most physicians treat patients with cutaneous
  verrucous carcinoma (VC) in their offices.
  Complete tumor extirpation should be performed at
  first presentation because verrucous carcinoma
  can recur, metastasize, and, ultimately, cause
  death. Recurrent verrucous carcinoma carries a
  relatively poor prognosis.

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Contd Tx

• Excision is the treatment of choice because of
  local aggressiveness and infrequent metastasis.
  In more serious cases, amputation may be
  necessary for cure.
• Mohs excision
• Provides a cure rate of 94-100 and has been of
  particular value in curing verrucous carcinoma
  with perineural invasion.
• Advantage over simple excision

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Contd Tx

• Radiation therapy offers the potential advantage
  of avoiding the trauma and deformity of a
  surgical procedure, but it has occasionally been
  associated with transformation to high-grade
  squamous carcinoma.
• Cutaneous verrucous carcinomas with variable
  success include topical or systemic chemotherapy
  (bleomycin, 5-fluorouracil, cisplatin,
  methotrexate), carbon-dioxide laser,
  intralesional interferon alfa, imiquimod, and
  photodynamic therapy

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Follow-up

• Verrucous carcinoma (VC) usually is cured with
  appropriate therapy. However, recurrence is
  possible.
• Patients are at risk for developing additional
  verrucous carcinoma and SCC
• Skin examinations at 3- to 12-month intervals.

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Q 1

• A 63-year-old man presented with a two-year
  history of a worsening verrucous lesion on his
  right foot. It had ulcerations with partial
  healing, and weight bearing caused pain (see
  accompanying figure). On physical examination,
  the patient was found to have a 4- 6-cm
  ulcerated verrucous plaque on the plantar surface
  of his forefoot. No other verrucous lesions were
  noted on the foot. Previous treatments included
  multiple excisions and topical agents for verruca
  vulgaris, which produced only limited
  improvement.

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Based on the patients history and physical
examination, which one of the following is the
correct diagnosis?

• A. Actinomycosis (Madura foot)
• B. Verrucous carcinoma
• C. Verruca plantaris
• D.Pseudoepitheliomatous hyperplasia.
• E. Plantar fibromatosis.

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Actinomycosis

• A chronic bacterial infection caused by
  gram-positive bacilli (Actinomyces sp.)
• Can present with fistulous tract lesions. Sulfur
  granules similar to the keratogenous material in
  the verrucous carcinoma may be present.

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Verruca Plantaris (Planter Warts)

• Non cancerous skin growth on soles due to HPV.
• Often develop on pressure points in your feet.
• Small, fleshy, grainy lesions, or growths, on the
  soles of your feet.
• Hard, thickened skin (callus) over a well-defined
  "spot" on the skin, where a wart has grown
  inwards
• Interrupt the normal lines in the skin.
• Pain or tenderness when walking or standing

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Planter Wart vs

• Planter Wart

• Callulous

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Actinic keratosis

• Superficial keratotic lesion that is a precursor
  for SCC.
• Appears as a discrete, reddish-pink keratotic
  lesion w/white scale that feels rough
• Sun-exposed areas, mostly hand and dorsal hands
• Dx Clinical presentation. Bx not indicated
• Tx Cryotherapy, topical 5-FU, imiquimod,
  photodynamic therapy.

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Squamous Cell Carcinoma

• Represents 20 of all skin cancers
• Arise within actinic keratoses, HPV-induced
  lesions, burns or radiation scars.
• More common than BCC in Immunocompromised
  individuals.
• Occurs anywhere but commonly sun exposed areas

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Contd SCC

• Hyperkeratotic lesion w/crusting and ulceration.
• Tx Surgical excision w/clear margins.
• Cx Higher rate of metastasis than BCC. 5-year
  recurrence rate is 8 and metastatic rate is 5.

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Basal Cell Carcinoma (BCC)

• Most common skin cancer (80).
• Occurs in sun exposed areas, especially central
  face and arm.
• Common over 40 yrs.
• Slowly growing.
• Shiny pearly papule with prominent
  telangiectatic surface vessels that develop as
  the lesion enlarges.
• Pigmented BCC which is often mistaken for
  melanoma.

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Contd BCC

• Dx biopsy
• Tx
• Excision or destruction (electrodesiccation and
  curettage).
• Mohs surgery
• BCC on head and neck
• Large BCC or recurring
• Metastatic spread occurs in lt0.1.
• Patient education sun avoidance

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Keratoacanthoma

• Well-defined, uniform, firm, flesh-colored to
  brown nodule w/central hyperketatotic plug.
• Low-grade tumor that originates in the
  pilosebaceous glands. Resembles SCC
• Rapid growth over a few weeks to months, followed
  by spontaneous resolution over 4-6 months in most
  cases.

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Malignant Melanoma (MM)

• Accounts for 3 to 5 of all skin cancers and is
  responsible for approximately 75 of all deaths
  from skin cancer.
• Malignancy of melanocytes.
• Persons with an increased number of moles,
  dysplastic atypical nevi, or a FH of the
  disease are at increased.
• CDKN2A is a gene associated w/familial melanoma.
• Evaluation for potential melanoma- ABCDE
  pneumonic.

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Types

• Melanoma in situ epidermis.
• Superficial spreading melanoma most common type.
  (70 ).
• Nodular 2nd most common. MgtF
• Lentigo maligna slowly growing. 60-80 yrs
• Subungal longitudinal line of pigmentation on
  the nail. Spread to nail foldsHutchinson sign
• Acral lentigous most common melanoma in black
  and asian population.
• Amelanotic melanoma Rare

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Diagnosis

• Any suspicious pigmented lesion should be
  biopsied.
• Methods include deep shave, punch, and
  excisional biopsy.
• It is important that the size of the specimen be
  adequate to determine the histologic depth of
  lesion penetration, called Breslow depth.
• Breslow depth and LN are important prognostic
  factors.

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Tx

• Excision with appropriate borders.
• Sentinel LN dissection for melanoma gt1mm thick to
  determine if adjuvant therapy is needed.
• Close follow up
• 5 yr survival rate w/LN involvement and distant
  metastasis are 30 and 10 respect.

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Keloid

• Hypertrophic scar
• Common in AA
• Rx Intralesional Corticosteroid. Surgical
  excision is not recommended.

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Q2

• A 79-year-old woman presented w/ a rapidly
  growing nodule on her leg six months following
  surgical excision of a basal cell carcinoma. The
  nodule was about 1 1 cm in size and located at
  the surgical site.
• PE revealed an erythematous and centrally
  hyperkeratotic nodule at the inferior margin of
  the surgical scar. The lesion began to regress
  after two months without treatment.

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Contd

• Based on the patient's historyand physical
  examination findings, which one of the following
  is the most likely diagnosis?
• A. Basal cell carcinoma recurrence.
• B. Dermatofibrosarcoma protuberans.
• C. Keloid.
• D. Keratoacanthoma.
• E. Subcutaneous fungal infection.

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• Answer Keratoaconthoma

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Q 3

• A 90-year-old female nursing-home patient has a
  1.52.0-cm lesion on her face. She states that
  the spot has been present for years and that it
  doesnt bother her. Closer examination reveals a
  flat maculopapular lesion with varying colors and
  an irregular border.

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• Which one of the following is the most likely
  diagnosis?
• A) Actinic keratosis
• B) Metastatic breast carcinoma
• C) Seborrheic keratosis
• D) Lentigo maligna melanoma
• E) Basal cell carcinoma

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A

• Lentigo maligna melanoma.

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Q 4

• Actinic keratoses of the skin may progress to
• A) nodular basal cell cancer
• B) pigmented basal cell cancer
• C) squamous cell cancer
• D) Merkel cell cancer
• E) malignant melanoma

48
A

• Actinic keratoses

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Q 5

• A 58-year-old white man presented to the
  outpatient clinic with a single asymptomatic
  nodule on his face that had appeared months
  earlier. He had no history of skin cancer. The
  nodule was 1.5 1 cm, translucent, and located
  below the right lateral lower eyelid. The nodule
  had not changed in size or color, and there was
  no drainage or bleeding.

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which one of the following is the most likely
diagnosis?

• A. Malignant melanoma.
• B. Melanocytic nevus.
• C. Pigmented basal cell carcinoma.
• D. Seborrheic keratosis.
• E. Solar lentigo.

51
A

• Pigmented BCC

52
Q 6

• A 78-year-old woman presented with a large growth
  on her face that had been present for 11 years.
  The lesion was located in the zygomatic region, a
  sun-damaged area with aged skin.
• Physical examination showed a hard, elongated,
  gray to yellowish hyperkeratotic mass. The lesion
  was 7.2 cm in length with a base diameter of 0.7
  cm.

53
Which one of the following is the most likely
diagnosis?

• A. Actinic keratosis.
• B. Cutaneous horn.
• C. Keratoacanthoma.
• D. Seborrheic keratosis.

54
A

• Cutaneous horn

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Q 7

• A 55-year-old man with a history of chronic
  alcoholism presented with pain under the tongue
  and discomfort when swallowing that had persisted
  for several weeks. The dorsal surface of the
  tongue had a relatively normal appearance.
  However, examination of the undersurface revealed
  a red and white exophytic growth along the
  posterolateral border of the right side of the
  tongue. The lesion was granular, irregular, and
  ulcerated. Cervical lymph nodes were palpable
  bilaterally.

56
Which one of the following is the most likely
diagnosis?

• A. Chronic traumatic ulcer.
• B. Deep fungal infection.
• C. Lymphangioma with surface ulcerations.
• D. Rhabdomyosarcoma.
• E. Squamous cell carcinoma.

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A

• SCC

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Questions ????

• Thank you