No,2936 p, 2

SquamOU$ Cell : A Pedal Case Presentation

Squamous cell carcinoma of the foot is a reiBl:ively uncommon pedal , The authors discuss the etiology, metastatic rare, incidence, morphology, treatment and the histology of rhls entity. Addlclonally, the authors presenr a clinical case report successfully treated by surgical extirpation.

John F. Grady, DPM, FACFS' Carol J. Moore, DPM3 Matthew G. Garoufalis, DPM2 Ronald Nasadowski, DPM4

Squamous cell have been described in the can metastasiz!;; to local lymph nodes (9). Metastasis literature by various nam.es, which include prickle cell tends to occur along lymphatic channels, with a low epithelioma, epidermoid carcinoma, spinous cell car­ incidence of hematogenous spread (2, 10), cinomOl, spinolioma, squamous epithelioma, verrucose Robbins et al. (10) state that when squamous cell carcinoma, epithelium cUI'liculamm, epidermoid car­ carcinoma OCCUI'S 011 sun-exposed skin, the patiems cinoma, and prickle cell carcinoma (1-3). Sq uamous that develop metasta~s are less than 2%. HowevCT) cell carcinoma is a malignant neoplasm of skin and squamous cell carcinoma has a significant potential for mucous membranes that has its origin from the epider­ metastasizing when arising on mucosal surfaces, mis or epidermal appendages where stratified squamous chronie ulcers, burn s~ars, genitalia, and areas of radio­ epithelium is found (4-6). dermatitis. Tllli; rate of occurrence has been reponed to be 20% 10 50% (10). Etiology Lund (4) descrihes four characreristics that seem to differentiate between metastasizing and nonmetasta­ WhiIe the most common predisposing factor is sizing squamous cell cardnoma. Tbe following have chronic sun exposure, there have been a number of been associa.ted with metastasizing malignancies: other underlying etiologic factors associated with the deve10pment of squamous cell carcinoma. These in­ l. Occur in OiSsociation with an etiology other than clude preexisting lesions such a~ IeukopJakia, actinic sun exposure; keratoses, xeroderma pigmentosulJ1, and cutaneous 2. The metastasizing lesions found hy Lund '(4) were horns. Other less common environmental factors ina alllargc in diameter. The smallest mcta.'>tatic le­ dude ingestion of arsenic, contat.1 with organic hydro­ sion was 1.3 cm. in diameler: carbons, tobacco use, radiation and thermal injury, 3. The lesions were all very invasive on histological chronic skin ulcerations or sinus tract<;, scars, and neu­ examination; and rodermatitis (6-8). 4, The metastatic tumors generally were found to be much less differentiated histologically than the Metastatic Rate nonmerastatic 1,:sion~. While the squamous cell C"'clrcinomas arising on Slln­ exposed skin are the most common, they typically are Incidence Jess aggressive and less likely to metastasize. The excep­ Brietsteill and Hugar (11") describe a male predomi. tion to tillS includes thosc squamous cell carcinomas nance of nearly 3 : I with the majorily developins be­ found on the ear

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Morphology Case Report Clinically, squamous cell carcinoma can appear as A 38·year-old black male was seen ill the Podiatry either papillary or ulcerative (5). Atypical verruC thelium. An increased number ofatypical cells, greater approxjmately 4 x 4 em., protrudillg 2 mm, from the ·1 degree of anaplasia, and an i)'lcrea.~ed number of mitotic plantar aspect of the left foo~ (Fig. 1). The mass wa<; I .. ! figures all indicate poor differentiation (1, 4, 10, 15). multi lobulated with awell-demarcated hyperpigmented Less differentiated epithelial cells correlate with a border. The lobes of the lesion were pink, and nonul- more aggressive tumor, according to Broder's grading system (1). Broder's gr<1ding system separates carcino­ mas from I to IV. The system begins at grdde J with this lesion having the least amount of mitotic flgures and anaplasia. As mitotic figures and anaplasia pro­ gress, the grading system correlates wilh this increase. Therefore, gr<1dc IV is the most aggressive and undit: ferentiatcd carcinoma (1, 15). Differential diagnoses should include basal cell epi­ thelioma, senile or actinic keratoses, psco.doepithelio­ matous hyperplasia, keratocanthoma, malignant mela­ noma, eccrine poroma, verruca plantaris, deep my· coses, pyogenic granuloma, amclanotic melanoma, and Bowen's disea.o;e (squamous cell carcinoma in situ (I, 2, 11 ).

Treatment It is essential that the physician consider the possible differential diagnoses and initiate an early biopsy and the necessary treatmenl. Treatment of these tumors include surgical c:(cision and primary closure, , curettage, electrofulguration, cryosurgery, and Mohs' chemosurgery. The eradication of the cancer must be the primary consideration of the physici'lll (3, Figure 1, Presentation of squamous celt carcinoma on the 15-21), plantar aspect of the toot.

376 THE JOURNAL OF FOOT SURGERY No.2936 P. 4

cerative. The lesion was cov~:red by very mild hyper­ A O.6-mm. punch biopsy was performed at the pe­ keratoses, and there was neither erythema nor l~dema riphery and revealed hjSlologic changes a~so,:jated with noted in this area. No pain could be elicired through squamous cell carc.:inon1a. The Surgical De­ direct or medial-to-lateral palpation. Radiographically, partment wa<:; consulti:'.d, and the decision to admit the there was no bone involvement. There was no popJite.tl. patient and pcrfonn a wide excision of the lesion was or inguinal lymph adenopathy. made. The excision removed the lesion, as well as approximately 3 em. of surrounding skin and soft tis-

L 1 j )

Figure 2. Papillary hyperkeratosis, acanthosis of squamous epithelium and unremarkable dermis (H & E 4 x 1.25 magni­ fication.)

f l f·

Figure 4. A and 8. Lack of organization of basal layer and atypical squamous cells tl'lroughout the epidermis. These atypical cells are pleomorphic, hyperchromatic. have in­ creased nuclear to cytoplasmic ratio and atypical mitotic Flgure~. Parail.t!lil105is, hypcr!-:eratos!s anti

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sue. A split-thickness skin graft was taken from the Acknowledgmenls contralaleral thigh and placed over the wound. The The authors thank the Pathology Department at the tissue specimell was sent to pathology, where the diag­ Westside Veteran's Administration Medical Center for nosis ofsquaml)US cell carcinoma was again confIrmed the preparation of the histologic slidl:s as shown in this (Figs. 2-4). The surgical margins were found to be fl'ee papel·. The authors also thank Ronald Jo11nso11, DPM, of tumor changes. at the Cl)llege of Podiatric Medicine and Surgery, and The patient was fallowed-up by the Surgical Oncol­ Chryst.lIla Daly, 00, in the Pathology Depanment at ogy Department to determine if any metastasis had The University of Osteopathic Medicine and Health occurred. No metastases were found and the prognosis Sciences, Des Moines, Iowa for their assistance in the for the patient was good. The patient healed without preparation of photomicrographs and the legends that complications (Fig. 5). Eleven months aftet' surgery, the appear in this article. patient had no Jocal recurrence of the carcinoma. A non tender scar remains. References l. SaueI. O. C. ManUIJi ()/Skill lJi$l!aSe!.\', 5th ed., p. 309, J. B. Lippincott, Philadelphia, 1985. Summary 2. Neufeld, R. r., Kuruell', C. M., Estersohn. H. S.. Napoli, 1. D. VertUcous squamous cell carcinoma of the foot: lI. r,m! case The literature is replete with a wide array of various histol1'. J. A. P. M. A. 75;300, 1985. 3. Steillh::l.1"t, A. N. Squamoull cell carcinoma of the sole: c,"ISC synonyms for squamOus cell carcinoma. Numerou~ presentation and review ot'the literatu[C. J. A. P. M. A. 10:330, causative agents have been cited as ctioh)gic factors. 1980. Studies have differed as to the incidence of this carci­ 4. Lund, H. "l. How often d()c:.~ sqUl.lmOlL~ cell carcinoma of the noma. skin meta.~tasi~l!!. Arch. Dermatol. 92:635. 1965. Clinically, squamous cell carcinoma can appear as 5. Levy, M., Glubo, S. M., Lenet. M. D.. Sherman. M. Squam()u~ cell carcinoma on the plantar surf.ce of the font. 1. A. P. M. A. either papillary orulcerative.lt is important that careful 72;471,1982. and accurdte histologic review of tissue ~amplcs be 6. Galinski, A. W., Williams, J. E., Geduldig, S. B. Squamous cell performed to arrive at an accurat~ diagnosis since there carcinoma: a review ofth.c literature and ClISC rtpQrt. 1. A. P. A. are many differential diagnoses to consider with this 71:505. /981. entity. The authors have presented a bl'ief literatw·e 7. Galinski. A. W., Shapiro, L 1., Waldman, M. Squamous ce[l review and also a clinical ease study of squamous cell can.'lnl)tru1 of the loot: a report of two cases 'Witl1 nail bed invalveml!!nt. J. A. P. A. 66:550. 1976. carcinoma. 8. Walt: W. B.. Cohen. C. S. Intr&c:pidl':TTIlal $CIUllmllu.~ cell card­ noro~ CAt)w~n's disease (If the t1o~um of tbl!! foot). J. A. P. A. /is:fi8S, 1978. 9. Wyngaarden, I. B.. Smith. L. H. (cd.) Cecil 'lexebQQkQj"M*ldif."inl!. 17th ed. pp. 2272-2297. W. R. Saun~krs, Philadelphia. 198.5. 10. Robbins, S. L., Cotran, R. S., Kumar, V. Pathologic Basis 0/ TJi:;eu.l'f!, 3rtl ed, p. 1266, W. B. Saunders. PbiL."Idelphia. 1984. 11. Brietsteill, R. 1.. HU8<'U. D. W. Squamous cell carciMma: com­ parative study lind case prc:senlalion.1. A. P. A 65:120, 1975. 12. Hoerr, S., Wllrnn, S. A study ofpalhologicallyverifJ.ed carcinoma Mthe skirl. Sucg. Gynecol. Obsta. 69:726. 1939. 13. DeMuth. R. i .. Snidl:T. ~. 1.. Primary squam()us cell cal'cinolnas oft,hl: pl:m'tllr surfllI,;C 11£ tne foul. Ann. Plasl. SUIi. 14:3 IO. 191$0. 14. Lc:vent:, M. Distl'ibution of Skill tumors of the sole ofth= foot. Br. Moo. 1.19:1519, 1958. 15. Spino:!."I. 1-". A. Squ:;mous cell can.inomll. M the plantar aspect of the fIIOt..T. Fool Sur&. 26:2.53,1987. 16. Goldner, R. The

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