HPI: The patient is a 70 y/o male who was referred by his primary care physician for a “bleeding wound” on the dorsum of his left foot.  The patient states that he had a lump develop on his foot during the summer and that in July his PCP “burned it off.”  The patient relates that the wound subsequently healed with a scab over the previous lesion site, and that approximately one month prior to his presentation in the office the scab fell off and this current lesion appeared underneath. He then returned to his PCP, who, in turn, referred the patient to the foot and ankle specialist.  He denies a previous history of similar lesions on his foot or elsewhere in his body.

PE: The patient is alert and oriented and in no apparent distress. He demonstrates palpable pedal pulses that are graded +2/4 at the dorsalis pedis and +1/4. On the dorsum of the left foot, the patient demonstrates a hyper-pigmented lesion that measures approximately 2cmx1.5cm, and is friable, and bleeds easily with abrasion.  The mass appears freely movable in the skin tissues and is mildly painful to palpation.  Sensation is grossly intact via 5.07 SMWF test to the distal distributions of the L4, L5, S1 nerve roots.  Proprioception and vibratory sensation is also intact.  Muscle strength is assessed and graded +5/5 in dorsiflexion, plantar flexion, inversion and eversion with no pain or crepitation noted on ankle of subtalar joint range of motion.

READ Complete Case Presentation in Residency Insight #31

Considering the history and clinical exam presented, how would you proceed with this challenging case?

Ryan presents an interesting case where in my mind I'm thinking.......Jeez this can't be good.  The previous surgical intervention by the PCP via electro-cauterization without the benefit of a punch biopsy may possibly complicate  the patient's eventual treatment to a lesser level of surgical intervention. This is why one should do a punch biopsy and NOT an excision or a shave biopsy so as to not complicate depth classification/treatment of such a lesion.
Differential diagnoses can include pyogenic granuloma, ulcerative forms of basal or squamous cell carcinoma, hemangioma (usually in pediatric patients and tend to resolve over time,) verrucous carcinoma, post-surgical keloid with secondary dermatological manifestations from shoe irritation, non-healing wound/ulceration from vascular embarrassment from electro-cauterization, Karposi sarcoma lesions, syphilitic lesions, malignant melanoma, etc.
Treatment would involve taking a thorough history to determine if the patient has had any other similar lesions excised with associated pathology reports if available. Sexual history of the patient is important to determine if the lesion may be the result of sexual etiology (HPV, HIV, syphilis.) A bacterial culture should also be considered. Next, I would take radiographs to rule out underlying osseous infection. Biopsy of the lesion would be strongly advised with documentation of biopsy sites to the pathologist where lesions were sampled. I would tend to take a few punch biopsies (not shaves) at the periphery of the lesion along with a central punch at the thickest portion of the lesion. If the lesion is determined to be malignant, classification/depth correlation to treatment has been compromised by the previous surgical treatment by the PCP. Intervention by an oncologist if malignancy is determined would be essential. Damn.....where are those TUMS?...LOL

The lesion is either in the skin, or the skin freely moves over it. The designation "freely movable in the skin" begs for defintion. In any case, this lesion is beyond a high index of suspicion, and it appears to have local satellite metastases already. The patient needs an immediate biopsy. When the malignant result ( I am betting on melanoma) is certain, referral for PET scanning, wide local excision and simultaneous sentinel node biopsy is required. If groin nodes are already present, and/or PET scanning is positive, all local intervention is moot.

I'm betting on a melanoma also. Anything like thatthat resembles something ulcerative is a melanoma until proven otherwise.

Ryan,

Nice case presentation.  I would agree with everyone's posts.  I am betting on melanoma, probably with late stage malignancy and metastatic disease.

This is probably not one of those "good" days you have in the office when you get the biopsy result back.

 

Judging by the blue surgical towel, looks like this patient made it to the OR for wide margin resection.

Was an MR done prior to see if this extends into deeper tissues?

Was oncology consulted?

My money is on Kaposi's Sarcoma. Looks like some vascular tumor variant to me.

What's the plan for soft tissue envelope recon?

Nice case. 

What is his Family History?   Obviously,  I am considering Kaposi's sarcoma,   

The diagnosis of Kaposi's Sarcoma would actually be a gift for this patient.  Any discussion of wide local excision and reconstruction is way pre-mature, as if this is melanoma, it will be surely invasive, with local intransit metastases already evident. If no evidence of spread beyond this point is found after scanning, the only treatment available is excision and isolated limb pefusion with chemo that is minimally effective. The only other purpose of local surgery would be to simply try and close the ulceration for quality of life purposes.

3 words....Biopsy...Biopsy...Biopsy.

Chris Seuferling, DPM

I had 4 thoughts come to mind: Kaposi’s sarcoma, melanoma, granuloma or a secondary reaction Herpes zoster lesion. I do not see an active bacterial infection here, so I would stay away from bacterial cultures. The Kaposi’s sarcoma cannot be ruled out, but I shy away from KS at this time because of the initial presentation description to the PCP as a “bump” on the foot (a biopsy would help).  Whatever, it has been altered/complicated by previous surgical treatment.  Since that previous treatment failed to eliminate the problem, I am inclined to go “deeper than the skin” for the etiology. 
A thorough PMH is essential with these dermal cases. Did he have chicken pox in the past?  If HSV-1 or HSV-2, particularly the latter, were involved in the past, I would start to think this was a Herpes zoster lesion, especially with the satellite lesions indicating a possible specific neuronal dermatome relation.  Although, the zoster lesion is usually seen on cervical, thoracic and sacral regions, do not rule out the uncommon zoster lesion that can develop on one foot or leg.  TEST IT:  A positive HSV viral culture of fluid from an active vessel could be diagnostic.  Also, the Tzanck’s smear and a biopsy would be helpful.  However, if he did not have CP, then I would lean toward a melanoma or pyogenic granuloma (PG) and do a biopsy anyway.

Worse to Least Worse:
Melanoma:  Malignant.  Biopsy with surgical intervention warranted.
Pyogenic granuloma:  Benign and potential to develop malignancy.  Biopsy and surgical intervention warranted.
Herpes zoster:  Benign and treatable without surgical intervention with acyclovir.  Biopsy and surgical intervention is useful but less warranted.
Nice case Ryan.  Let us know what you found.

I agree, KS vs Melanoma with possible mets.

Nice case, Ryan.

You will let us know, right? Very good case.

As I have been reading everyone's posts, I have to imagine that this is one of those cases that can either make you look like a hero or you wind up as one of PICA's "situational" case studies during their Risk Management lectures at one of te various meetings.

The other issue that I see with Ryan's case, after reviewing it in this thread and in the full posting, is that it can put what the internist/family practice doc did in "burning" it off, instead of referring to one of his or her dermatology or oncology buddies.  Now this also may be an instance where the podiatrist for this case is the only dermatological/surgical specialty in a rural area. Either way, this lesion has been there for a long time and was either not disclosed by the patient or was missed on physical examination by the IM/GP (assuming the patient had regular office visits).

Either way, the base decision to biospy (either combination of multiple punch and/or shave) and referral to surgical oncology is probably in the best interest.

I really have to disagree with any type of wide resection surgical decision pending pathology results.

Eric 

punch biopsy to be done by yourself or referred to dermatologist and wait for results.  either way I believe the patient will need oncology service down the road.  Differential diagnoses have been mentioned by numerous readers above.

My differential diagnosis; KS vs. Melanoma vs. Zebra (everything else).

Yes, I think a punch biopsy or incisional biopsy is warranted.

I have a middle-age Persian (Iranian) male, HIV-negative, with confirmed Kaposi Sarcoma lesion on the foot. KS is classically presented in middle-Eastern descendants only, unless they are HIV positive.

My KS patient's lesion does certainly look like this Ryan's case, with a pigmented, raised lesion that ulcerates. I was told by his oncologist (to my surprise) that KS in non-HIV patients are not necessarily lethal, but more of nuisance as it can invade to lymph nodes and cause lymphedema etc. In my patient's case, he is responding to chemo therapy well, and the disease appears to be contained.

See the picture below... the KS lesions have been burned off with laser (by a dermatologist) and I have been providing local wound care.

 

This interesting case illustrates nice local management of a deeply invasive lesion. However, I could make a good case that the order in which care has been planned should have been different. Firstly, before any surgery was done, it was obvious that if malignant, there was already in transit metastases evident in the surounding skin. This  means that the lesion is METASTATIC. It does not mean much that the evident mets are close to the original lesion.  As an example, a met located close to the original dooms the survival statictics as badly as one if it were on the scalp. Therefore, my choice would have been: 1) Multiple punches to confirm invasive melanoma 2) Oncology referral for PET scanning 3) Depending on PET results, wide local excision with sentinel node dissection at the SAME OPERATIVE SESSION WHICH IS CRITICAL, AND BETTER IF YOU BELEIVE THAT THIS PROCEDURE IS BOTH PROGNOSTIC AND THERAPEUTIC, which is currently controversial. But doing a sentinel node at a different operative session after the wide local excison is definitely not optimum because the procedure is based on the priciple that every spot in the skin has its unique lymph drainage path, and in this case, that spot and a lot of tissue around it is now gone. Had the PET scan revealed liver metastases, we may have not even proceded to the wide local excison ecxept as needed for palliative measures. Lastly, isolated limb chemoperfusion may now be contraindicated because of the extent of the local surgery. already done.  In any case, the survival statistics just based on the original path are very grim in this case, so all may be moot. However, we all are going to be faced with malignant skin and soft tissue evaluations in the future, and I have begged for years that you all respect that this area of medicine is very highly specialized and as far away from main stream podiatric surgery as anything could be. I have my detractors, but my everyday life demonstartes that the deft ability to perform these procedures does not necessarily make one the best choice of caregiver.

I agree whole-heartedly with Dr. Markinson.  There is no need to do a wide excision right away without knowing if there is metastases.  I believe a biopsy could have been performed in the office.  Once the pathology report came back as nodular melanoma, an oncology consult should have been immediate before doing anything else.  Since you did take the patient to the OR for excisional biopsy, I feel that once you got the initial frozen section results from the pathologist which were very grim, the case should have stopped there.  Maybe you would have been able to close the wound until oncology gave their recommendations on definitive surgical or non-surgical treatment.  Now, your patient has to deal with a wound which is probably painful, at high risk for infection, and impacts their quality of life tremendously while waiting on tests to confirm metastases.   In this case, getting clean margins right away was not a priority in my opinion, just as Dr. Markinson has said.  Statistically we all know your patient probably has a very poor prognosis at this point considering the staging and aggressiveness of the lesion.  Metastasis to the liver is probable.  If that is the case, it doesn't really matter if you got clean margins or not.  In saying that, I hope I am wrong with my critique and that you just saved a man's life and his limb with your surgical expertise and decision to achieve clean margins right away.  Thanks for presenting your case, and we all hope this patient never walks into any of our offices!

This is certainly an interesting case that you don't see everyday. Thank you, Ryan, for sharing the case with us.

Unfortunately, I think I agree with the other commentators that this patient's prognosis is grim, notwithstanding the wide excision of the entire lesion and very nice coverage with Integra. I also highly respect Dr. Markinson's opinion. I thank you for your comments, Dr. M.

The biggest thing that bugs me... the PCP's decision to "burn off" the lesion. This goes to show you that we shouldn't be burning any pigmented skin lesion that walks through the door, without thinking ahead of the consequences. I wonder if the PCP has legal defense for his/her rationale for the treatment, should the patient decide to litigate on the basis of "pain and suffering." 

I agree with the above posts when I read the treatment rendered. Wide excision without PET scan results may be "putting the cart before the horse." If there is evidence of metastatic disease, what would be the point of a wide excision/resection? Even if clean margins were obtained, what would be the medical-surgical goal without definitive knowledge that metastases are not present?   In addition, if there was metastatic disease and the patient would then be placed on radiation/chemotherapy the use of the temporary coverage of the wound may be problematic. You now have an immunocompromised, most likely terminal patient, with a wound to contend with, susceptible to  infection and non-healing. If the PET scan was negative for metastatic disease along with lymph node biopsy, Ryan's staging of this procedure would be ok. However, let me be a devil's advocate here, does the initial burning off of the lesion by the primary doctor without biopsy not predispose this course of treatment without PET scans/lymph node biopsies to potential liablility?
This is not to be taken as a criticism of the treatment rendered but to initiate reflection/debate amongst us colleagues. Maybe, I'm just showing my age in being a chicken s*it.

To answer Dr. Scartozzi's, question, the solution is simple.

Very few of us are sufficiently trained in the management of tumors, both benign and malignant of the soft tissues and of skin. Going to Russia five times, and any available credential bestowing elite status in podiatric surgery does not, and will not ever change this fact. Truth be told, the same is true of orthopedic surgeons, general surgeons, vascular surgeons, etc, who have not had specialty fellowship training in oncology, pathology or musculoskeletal oncology surgery.
People confuse ability with knowledge, and in the case of tumors, this can be disastrous.

Regarding the question of liability - the patient was most likely doomed before he ever saw Ryan. That argument could be made very convincingly, but a jury actually "getting it" is completely another story. The delayed diagnosis caused by the primary care doc who "burned" it and never got a biopsy is very hard to defend, but possibe, and it may be just as well that the patient was doomed before that visit. But failure to get a biopsy also doomed that defense argument. It is very complicated indeed.

So well said, Bryan. I have lived those words, I admit with great humility.

A UT resident, who is now a terrific academic and well-respected practitioner, brought to the OR a "no doubt about it" lesion that happened to be attached to a human being. The two of us saw that huge malignancy on the end of the woman's hallux and so what did we do? We amputated the hallux, in order to (we thought) get the specific diagnosis, the depth, the staging, idea of extension into the area, etc., etc., etc.

Now this might have passed as "okay" if the chairman of our Orthopaedics Department had not been an orthopedic onocologolic surgeon. Oh yea. I got as far as the sinks before he nailed me in his quiet way. "Dr. Satterfield, what exactly were you thinking?" I tried my explanation and it did not fly one foot. (No pun intended.)

"Did you an MRI? Did you get a chest x-ray? What kind of blood work did you do? Did you call the Cancer Therapy and Research Center to arrange a team meeting? (Standard here, I found out.)"

After everything I did wrong, he made sure that I was kept informed about her progress. A few months later, I had a patient in whom I diagnosed an osteosarcoma. I called my chairman. This time it worked just fine.