Ryan Fitzgerald, DPM
PRESENT RI Associate Editor
Hess Orthopedics &
Sports Medicine,
Harrisonburg, Virginia
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Case Presentation Conclusion:
Suspicious Soft Tissue Mass
There have been some excellent responses regarding this challenging case on the eTalk thread on this topic at PRESENT Podiatry! As many of you surmised, the concern regarding this lesion was the likelihood that it was a malignancy. Among the differential diagnoses, kaposi’s sarcoma, malignant melanoma, pyogenic granuloma or a secondary reaction Herpes zoster lesion were considered as possible likely candidates, and considering the absence of previous biopsy data, the patient was brought to the operating room for an excisional biopsy (Fig.1). The patient was consented for both an excisional biopsy as well as wide radical excision, should the intra-operative pathology report require more aggressive intervention.
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| Figure 1:
The patient was consented for excisional biopsy with fresh, frozen section. |
Due to the high clinical suspicion of malignancy, the specimen was sent for fresh, frozen section to be evaluated immediately by the on-call pathologist (fig.2).
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| Figure 2: An 8cm ellipse was created which included the majority of the lesion and sent to pathology for fresh, frozen section. |
Upon pathological evaluation, the lesion was determined to be a nodular malignant melanoma with vascular invasion and multiple satellite lesions (fig. 3).
NOTE #1: Nodular malignant melanoma. |
Growth Phase: Vertical.
Clark's Level: V
Breslow Depth: 5.25 mm.
Mitotic Rate (Rate/mm2): 5
Satellitosis: Yes, extensive.
Regression: No.
Ulceration: Yes.
Host Response: Non-brisk.
Vascular Invasion: Yes
Surgical Margins: Tumor present in vasucalr spaces abutting dep margin (see note #2)
Pathologic Stage: pT4b
NOTE #2: Malignant melanoma extends at the skin surface to within 1.1 cm of the 12-3 o'clock edge, and is present in vascular spaces 0.8 cm fromthe 12-3 o'clock and 3-6 o'clock edges and abuts the deep margin.
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| Figure 3: The patient demonstrated a nodular malignant melanoma with vascular invasion and multiple satellite lesions. |
Additionally, it was determined that there was malignant tissue along the margins of the original tissue ellipse. Upon discussion with the pathologist, the decision was made to perform a further wide resection with margins greater than 1 cm from the original ellipse (fig 4 a-c). This tissue was determined to be free of malignancy.
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| Figure 4a: The patient following the original skin ellipse. The sutures visible demonstrate blood vessels that had extended into the lesion and were ligated prior to lesion excision. |
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| Figure 4b: Further wide excision of the dorsal foot. This tissue was sent to pathology and determined to be clear of malignancy. |
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| Figure 4c: Following radical wide excision, the patient was left with a significant degloving of his dorsal foot. The tendons and adipose tissue visible were resected and sent for pathological evaluation. |
Following radical wide excision, the patient was left with a significant degloving of his dorsal foot. Considering the vertical growth demonstrated by nodular melanoma, the tendons and adipose tissue visible in fig. 4c were resected and sent for pathological evaluation. The dorsal subcutaneous tissue demonstrated malignant cells, however the underlying tendon tissue appeared to be free from invasion.
Considering the significant dorsal tissue loss and subsequent exposed bone the decision was made to utilize IntegraTM bilayer collagen matrix which is a dermoconductive bioengineered alternative tissue and in this instance will be utilized to provide temporary wound coverage, thus reducing the risk of infection while the patient is sent for oncology consultation and a definitive surgical plan is developed (fig. 5).
The patient was referred to the melanoma specialist at a nearby University hospital for sentinel node biopsy, PET scan, and other work-up for possible (and likely) metastatic disease.
Discussion:
Malignant melanoma is the most serious form of skin cancer because, among the skin cancers, it is the most likely to spread to lymph nodes and internal organs. Today, melanoma accounts for 77% of all deaths from skin cancer. Nodular melanoma is of specific concern, because unlike other forms of melanoma, nodular melanoma does not have a horizontal, expansitile growth phase prior to the development of vertical growth and tissue invasion. Additionally, Instead of arising from a pre-existing mole, nodular melanoma may appear in a spot where a lesion did not previously exist. Nodular melanoma accounts for approximately 15% of all melanoma cases in the United States.
As many of those who participated in the eTalk thread on this case presentation, when faced with a suspicious soft tissue lesion, a biopsy should be performed to evaluate for possible malignancy—It may give you the time to intervene to save someone’s limb and life.
We at PRESENT appreciated the excellent participation in the case presentation and I encourage you to post your interesting cases in the eTalk section of PRESENT podiatry to promote our collective knowledge. We look forward to hearing from you!
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The Diabetic Charcot Foot: Principles and Management
by Robert G. Frykberg DPM, MPH, Editor |
| This text provides the reader with the most current information available on the pathogenesis, natural history, and management of the diabetic Charcot foot.
Many of the world's experts have come together to present their unique perspectives on this disorder. It is our hope that this work can become a valuable resource for those less familiar with the peculiarities of this often misunderstood complication of peripheral neuropathy. I am indebted to each author for the contribution of their time, efforts and expertise. |
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