HPI:The patient is a 36 y/o female with a history of paraplegia who presents with lymphedema and a history of bilateral soft tissue masses that was admitted to the hospital for increasing drainage from the left foot mass. Due to the paraplegia, the patient has a care-giver who assists in her care and that provider related to noticing foul smelling drainage from the left foot location. The patient relates no history of trauma that she is aware of, and denies any recent history of fevers, chills, nausea, vomiting, chest pain, SOB, or any constitutional symptoms.

PMH:Paraplegia, Diabetes Mellitus, Lymphedema, Morbid Obesity

PSHx: Cholecystectomy, Appendectomy

Fam Hx: CAD, Diabetes

Vital Signs

T:98.3, BP:130/84, HR 99, pain 0, resp: 18, SPO2  98% on Room Air

Physical Exam:

The patient is alert and oriented; she demonstrates appropriate mood and affect, is morbidly obese and is in no apparent distress. Upon evaluation of the bilateral lower extremities, the patient demonstrates pedal pulses which are palpable and graded 2/4 at the dorsalis pedis and the posterior tibial arteries.  There is evidence of bilateral lower extremity edema secondary to lymphedema and there is pitting noted. There is loss of protective sensation and no muscle function noted. The patient demonstrates evidence of soft tissue masses along the plantar aspect of the feet bilaterally. On the right foot (fig. 1) the patient demonstrates a soft tissue mass centrally along the plantar aspect of the midfoot and on the left foot, the patient demonstrates evidence of a mass inferior to the 4thdigit in the area of the sulcus.

Considering these clinical Findings, How would you proceed?

See Clinical Images below:

LG Preop Right

LG Preop Left

  • Comments (26)
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  • 1.  What about taking a frozen section analysis of an open biopsy before excising the entire lesion?

    2. If the pathology report came back instead malignant what would be the next step?

  • I was (am) in agreement regarding the nature of the pathology report --especially the absence of a specific diagnosis.  The samples have been sent, at my request, to an outside dermatopathologist, for second opinion, and we are awaiting the results.  From a clinical standpoint the patient continues to do well, so i'm hopeful that this will be more esoteric than actionable information once it arrives.

    All good points!

  • So, was there ever a definitive dx given?

  • What a great teaching thread!

     

    We all must keep an open mind to the nil. Sometimes what began as a professorial position becomes one of being the student. That's IMHO, what makes a great professor.

    Here at Present, most of us remain, with every posting we post, professors and students simultaneously.

    After all, a professor who is always right eventually loses the trust of his/her bloodline.

    Most of all, I think this discussion, being held largely by DPM's, points to the specialized knowledge that we have as closed chain specialists when it comes to any skin lesion that is accepting the punishment of weightbearing.

    We, and the pathologists we rely upon, must be vocal in order to justifiably hold a large slice of the dermpath pie when it comes to "Closed Chain Dermatology".

    Dennis

  • What a terrible path report.  You should send a sample to Dr. Bakotic at Bako.  http://www.bakopathology.com/

    6240 Shiloh Road
    Alpharetta, GA  30005
    1-877-376-7284
     
    They'll give you a thorough report.
  • I agree.  Were the stained tissues not differentiated enough to render a diagnosis, rather than a description ?

  • Dr. Albreski is 100% correct. This is an inferior biopsy report. Did a dermatopathologist take a look? Were special stains done? Did they look through deepeer sections? I highly recommend a discussion with the pathologist regarding these questions. Also, frozen section on skin lesions are very unreliable, even thoigh the report says that the final pathology did not result in any different findings. Still - a closer look is required here.

  • I totally agree with sending all lesions of question to pathology, although when we send tissue for identification the diagnosis is only as good as the report. We often interpret reports as malignant versus benign. This report confirms non malignant lesion, although doesn't provide cellular identification. Inflammation? We all have seen spongiotic changes, epidermal and dermal, although not stated within this report. Photos clearly showed a well circumscribed mass growing through the epidermis, possible dermal which would rule out Kaposi and epi/ dermal pathology. Without a pathology report identifying the subcutaneous lesion, I believe we are are not giving our patients justice. Spending 13 years as an associate professor in dermatology at University of Connecticut I would ask much more from my pathologist. If possible, offline, please send me the blocks and slides and I will have this case reviewed by a few of my derm pathology colleagues. I feel this report lacks specific details of the underlying etiology.
  • So Ryan, when do we get the rest?

  • Quote:

    Quote:

    I have had two cases of Kaposi's Sarcoma this year and neither presented with history of AIDS or Mediterranean descent.  These lesions appear similar to the lesions I had encountered.


    Sudad, were they African or on immunosuppressant drugs?  What do you think the etiology of the Kaposi's was?  I've never had a case of Kaposi's.


    Carla, they were both African American and neither was on immunosuppressants medications.  We had both worked up for HIV and negative in both cases.  Not sure what the cause of the Kaposi's was, not clear and was worked up by Dermatology before referred to me for excision.  However we treated with liquid nitrogen weekly until resolved as the pt did not want surgical excision (one small lesion was excised for biopsy)

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